TY - JOUR
T1 - Self-management interventions for people with chronic obstructive pulmonary disease
AU - Schrijver, Jade
AU - Lenferink, Anke
AU - Brusse-Keizer, Marjolein
AU - Zwerink, Marlies
AU - van der Valk, Paul D.L.P.M.
AU - van der Palen, Job
AU - Effing, Tanja W.
N1 - Funding Information:
Source of funding: this study was supported by Boehringer Ingelheim, Eastern Melbourne Primary Health Network, Lung Foundation Australia and National Health and Medical Research Council.
Funding Information:
Source of funding: supported by NHLBI grant R01 HL09468 (RB, principal investigator) from the National Institutes of Health
Funding Information:
4. COPD exacerbations (self-reported), measured by the question: ‘How often during the previous 6 months have you had a serious exacerbation of the lungs?’ Source of funding: this research was funded by the Icelandic Research Fund, University of Iceland’s Research Fund, Landspitali-University Hospital’s Research Fund, Icelandic Nurses’ Association’s Research Fund, and the Oddur Olafsson Fund.
Funding Information:
Source of funding: this work was supported by the National Health and Medical Research Council (NHMRC) project grant ID490028, a Royal Hobart Hospital Research Foundation grant and a University of Tasmania Institutional Research Grant.
Funding Information:
Source of funding: this work was supported by the Western Norway Regional Health Authority [grant number 2013/911836] and the Norwegian Extra Foundation for Health and Rehabilitation [grant number 2015/RB13639]
Funding Information:
This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to the Cochrane Airways Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS, or the Department of Health and Social Care.
Funding Information:
Source of funding: this study was funded by NEXES (Supporting Healthier and Independent Living for Chronic Patients and Elderly).
Funding Information:
Source of funding: this study was supported by South Link Health Inc., a nonprofit consortium of general practitioners.
Funding Information:
Source of funding: a grant from Robert Wood Johnson Foundation
Funding Information:
Source of funding: this study was supported by an unrestricted grant from the Veterans Integrated Service Network 23 Primary Care and Research Services and by the Center for Chronic Disease Outcomes Research, a Veterans Affairs Health Services Research and Development Center of Excellence Conflict of interest: several study authors (i.e. K.L.R., M.C., D.E.N.) reported that they or family members received financial benefits from a commercial entity. The other study authors (i.e. H.E.B., J.G., T.M.S., D.B.N., S.K., M.T., L.J.G., C.B., do not have financial relationships with a commercial entity that has an interest in the subject of this manuscript
Funding Information:
Completed second year of follow-up: N = 175 (based on provincial health insurance and hospitalisation database records) Source of funding: this study was funded by an unrestricted grant from Boehringer Ingelheim Canada, Burlington, Ontario, in partnership with the Fonds de la Recherche en Santé du Québec (FRSQ), Montreal, Quebec.
Funding Information:
Self-management materials based on the "Living Well with COPD" programme and previously adapted for the UK population and healthcare setting by an iterative process, were used (p. 2). Extra information from author: "We used adapted “Living with COPD” booklets and daily diary cards (Stockley et al. – originally developed for use in Bronchiecistasis, piloted these and adapted them for this study, to include a line for recording steroid and antibiotic usage." Source of funding: in addition to funding from the Chief Scientist Office, Scottish Health Department (CZH/4/246), this study was supported by educational grants from Boehringer Ingelheim, GlaxoSmithK-line, and Astra Zeneca.
Funding Information:
Source of funding: SJS and KR were supported by the Collaboration for Leadership in Applied Health Research and Care, East and West Midlands, respectively, and the NIHR Leicester Respiratory Biomedical Research Unit (BRU).
Funding Information:
Source of funding: the work described in this paper was supported by a grant from the Education Department of Guizhou Province, China.
Funding Information:
Source of funding: this trial was funded through the Building Bridges to Integrate Care (BRIDGES) program led by the University of Toronto’s Departments of Medicine and Family and Community Medicine and funded through the Ministry of Health and Long Term Care. L. Rose holds a CIHR New Investigator Award. Funding information for this article has been deposited with the Crossref Funder Registry.
Funding Information:
Conflict of interest: MJ Abramson reports grants from Boehringer Ingelheim, during the conduct of the study; grants from Pfizer, assistance with conference attendance and personal fees for consultancy from Sanofi, outside the submitted work. G Russell has nothing to disclose. AE Holland is a current member of the Lung Foundation Australia COPD-X: Concise Guide for Primary Care Advisory Committee. NA Zwar is a current member of the Lung Foundation Australia COPD Guidelines Committee. B Bonevski has nothing to disclose. A Mahal has nothing to disclose. P Eustace has nothing to disclose. E Paul has nothing to disclose. K Phillips is the Lung Foundation Australia General Manager of Consumer Programs. The Lung Foundation Australia works in collaboration and receives funding from pharmaceutical companies outlined in the foundation’s annual reports (available at lungfounda-tion.com.au/about-us/annual-reports/). NS Cox has nothing to disclose. S Wilson has nothing to disclose. J George reports grants from Boehringer Ingelheim, during the conduct of the study; grants from Pfizer, and personal fees for consultancy from GlaxoSmithKline, outside the submitted work; and is a current member of the Lung Foundation Australia COPD Guidelines Committee. J Liang has nothing to disclose.
Funding Information:
The Background and Methods sections of this review are based on a standard template used by Cochrane Airways. We thank the Cochrane Editorial Team, consisting of Rebecca Fortescue (Co-ordinating Editor), Liz Stovold (Information Specialist), Emma Dennett (Managing Editor), and Emma Jackson (Assistant Managing Editor), who commented critically on the review. We would also like to thank Lucy Goldsmith and Rebecca Fortescue for their critical comments and helpful discussions regarding statistical issues. The authors and Cochrane Airways? Editorial Team are grateful to peer reviewers Ana Isabel Gonzalez-Gonzalez (Spain) and Karen Royals (Australia) for their time and comments on this review. We would like to thank the following study authors for their assistance: R And?jar-Espinosa (Sanchez-Nieto 2016), R Benzo (Benzo 2016), E Bischoff (Bischoff 2012), J Bourbeau (Bourbeau 2003; Kessler 2018), D B?sch (B?sch 2007), H Bringsvor (Bringsvor 2018), C Bucknall and A McConnachie (Bucknall 2012), H Cameron-Tucker (Cameron-Tucker 2016), S Cheng (Cheng 2017), A Collinsworth (Collinsworth 2018), D Coultas (Coultas 2005), C Emery (Emery 1998), V Fan (Fan 2012), A Hussey and C Licskai (Ferrone 2019), J Garcia-Aymerich (Garcia-Aymerich 2007), J George (Liang 2019), R Goldstein (Hill 2010), C Hern?ndez (Hern?ndez 2015), K Heslop-Marshall (Heslop-Marshall 2015), V Johnson-Warrington (Johnson-Warrington 2016), K Jolly (Jolly 2018), H Jonsdottir (Jonsdottir 2015), A Lenferink (Lenferink 2019), F Ko (Ko 2016), K Mitchell (Mitchell 2014), I Orts (Folch-Ayora 2019), K Rayce (withdrawn study, no reference), K Rice (Rice 2010), L Rose (Rose 2018), J Stevens (Bohingamu 2018), M Tabak (Tabak 2014), R Taylor (Martin 2004), S Taylor (Taylor 2012b), E Titova (Titova 2015), J Walters (Walters 2013), and A Zakrisson (Zakrisson 2019). This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to the Cochrane Airways Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS, or the Department of Health and Social Care.
Funding Information:
Source of funding: Central Norway Regional Health Authority and the Research Council of Norway
Funding Information:
Tong C, Hart D, Corna N, Forbes-Faulkner L, Goodman M, al Masson S. Application of self-management systems evaluation trial (asset) for COPD patients in counties manukau (funded by the primary health care innovations fund). Respirology 2012;17:TP-180.
Funding Information:
Source of funding: this work was supported by grants from the National Heart, Lung and Blood Institute (HL45290) and the National Institute on Aging (AG00029).
Funding Information:
Source of funding: this study was funded by the Netherlands Organisation for Health Research and Development (ZonMw) and Partners in Care Solutions for COPD (PICASSO).
Funding Information:
Source of funding: NL Agency, a division of the Dutch Ministry of Economic Affairs (grant CALLOP9089)
Publisher Copyright:
Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
PY - 2022/1/10
Y1 - 2022/1/10
N2 - Background: Self-management interventions help people with chronic obstructive pulmonary disease (COPD) to 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 them to control their disease. Since the 2014 update of this review, several studies have been published. Objectives: Primary objectives. To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of health-related quality of life (HRQoL) and respiratory-related hospital admissions.
To evaluate the safety of COPD self-management interventions compared to usual care in terms of respiratory-related mortality and all-cause mortality. Secondary objectives. To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of other health outcomes and healthcare utilisation.
To evaluate effective characteristics of COPD self-management interventions. Search methods: We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, EMBASE, trials registries and the reference lists of included studies up until January 2020. Selection criteria: Randomised controlled trials (RCTs) and cluster-randomised trials (CRTs) published since 1995. To be eligible for inclusion, self-management interventions had to include at least two intervention components and include an iterative process between participant and healthcare provider(s) in which goals were formulated and feedback was given on self-management actions by the participant. Data collection and analysis: Two review authors independently selected studies for inclusion, assessed trial quality and extracted data. We resolved disagreements by reaching consensus or by involving a third review author. We contacted study authors to obtain additional information and missing outcome data where possible. Primary outcomes were health-related quality of life (HRQoL), number of respiratory-related hospital admissions, respiratory-related mortality, and all-cause mortality. When appropriate, we pooled study results using random-effects modelling meta-analyses. Main results: We included 27 studies involving 6008 participants with COPD. The follow-up time ranged from two-and-a-half to 24 months and the content of the interventions was diverse. Participants' mean age ranged from 57 to 74 years, and the proportion of male participants ranged from 33% to 98%. The post-bronchodilator forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) ratio of participants ranged from 33.6% to 57.0%. The FEV1/FVC ratio is a measure used to diagnose COPD and to determine the severity of the disease. Studies were conducted on four different continents (Europe (n = 15), North America (n = 8), Asia (n = 1), and Oceania (n = 4); with one study conducted in both Europe and Oceania). Self-management interventions likely improve HRQoL, as measured by the St. George’s Respiratory Questionnaire (SGRQ) total score (lower score represents better HRQoL) with a mean difference (MD) from usual care of -2.86 points (95% confidence interval (CI) -4.87 to -0.85; 14 studies, 2778 participants; low-quality evidence). The pooled MD of -2.86 did not reach the SGRQ minimal clinically important difference (MCID) of four points. Self-management intervention participants were also at a slightly lower risk for at least one respiratory-related hospital admission (odds ratio (OR) 0.75, 95% CI 0.57 to 0.98; 15 studies, 3263 participants; very low-quality evidence). The number needed to treat to prevent one respiratory-related hospital admission over a mean of 9.75 months' follow-up was 15 (95% CI 8 to 399) for participants with high baseline risk and 26 (95% CI 15 to 677) for participants with low baseline risk. No differences were observed in respiratory-related mortality (risk difference (RD) 0.01, 95% CI -0.02 to 0.04; 8 studies, 1572 participants; low-quality evidence) and all-cause mortality (RD -0.01, 95% CI -0.03 to 0.01; 24 studies, 5719 participants; low-quality evidence). We graded the evidence to be of ‘moderate’ to ‘very low’ quality according to GRADE. All studies had a substantial risk of bias, because of lack of blinding of participants and personnel to the interventions, which is inherently impossible in a self-management intervention. In addition, risk of bias was noticeably increased because of insufficient information regarding a) non-protocol interventions, and b) analyses to estimate the effect of adhering to interventions. Consequently, the highest GRADE evidence score that could be obtained by studies was ‘moderate’. Authors' conclusions: Self-management interventions for people with COPD are associated with improvements in HRQoL, as measured with the SGRQ, and a lower probability of respiratory-related hospital admissions. No excess respiratory-related and all-cause mortality risks were observed, which strengthens the view that COPD self-management interventions are unlikely to cause harm. By using stricter inclusion criteria, we decreased heterogeneity in studies, but also reduced the number of included studies and therefore our capacity to conduct subgroup analyses. Data were therefore still insufficient to reach clear conclusions about effective (intervention) characteristics of COPD self-management interventions. As tailoring of COPD self-management interventions to individuals is desirable, heterogeneity is and will likely remain present in self-management interventions. For future studies, we would urge using only COPD self-management interventions that include iterative interactions between participants and healthcare professionals who are competent using behavioural change techniques (BCTs) to elicit participants' motivation, confidence and competence to positively adapt their health behaviour(s) and develop skills to better manage their disease. In addition, to inform further subgroup and meta-regression analyses and to provide stronger conclusions regarding effective COPD self-management interventions, there is a need for more homogeneity in outcome measures. More attention should be paid to behavioural outcome measures and to providing more detailed, uniform and transparently reported data on self-management intervention components and BCTs. Assessment of outcomes over the long term is also recommended to capture changes in people's behaviour. Finally, information regarding non-protocol interventions as well as analyses to estimate the effect of adhering to interventions should be included to increase the quality of evidence.
AB - Background: Self-management interventions help people with chronic obstructive pulmonary disease (COPD) to 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 them to control their disease. Since the 2014 update of this review, several studies have been published. Objectives: Primary objectives. To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of health-related quality of life (HRQoL) and respiratory-related hospital admissions.
To evaluate the safety of COPD self-management interventions compared to usual care in terms of respiratory-related mortality and all-cause mortality. Secondary objectives. To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of other health outcomes and healthcare utilisation.
To evaluate effective characteristics of COPD self-management interventions. Search methods: We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, EMBASE, trials registries and the reference lists of included studies up until January 2020. Selection criteria: Randomised controlled trials (RCTs) and cluster-randomised trials (CRTs) published since 1995. To be eligible for inclusion, self-management interventions had to include at least two intervention components and include an iterative process between participant and healthcare provider(s) in which goals were formulated and feedback was given on self-management actions by the participant. Data collection and analysis: Two review authors independently selected studies for inclusion, assessed trial quality and extracted data. We resolved disagreements by reaching consensus or by involving a third review author. We contacted study authors to obtain additional information and missing outcome data where possible. Primary outcomes were health-related quality of life (HRQoL), number of respiratory-related hospital admissions, respiratory-related mortality, and all-cause mortality. When appropriate, we pooled study results using random-effects modelling meta-analyses. Main results: We included 27 studies involving 6008 participants with COPD. The follow-up time ranged from two-and-a-half to 24 months and the content of the interventions was diverse. Participants' mean age ranged from 57 to 74 years, and the proportion of male participants ranged from 33% to 98%. The post-bronchodilator forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) ratio of participants ranged from 33.6% to 57.0%. The FEV1/FVC ratio is a measure used to diagnose COPD and to determine the severity of the disease. Studies were conducted on four different continents (Europe (n = 15), North America (n = 8), Asia (n = 1), and Oceania (n = 4); with one study conducted in both Europe and Oceania). Self-management interventions likely improve HRQoL, as measured by the St. George’s Respiratory Questionnaire (SGRQ) total score (lower score represents better HRQoL) with a mean difference (MD) from usual care of -2.86 points (95% confidence interval (CI) -4.87 to -0.85; 14 studies, 2778 participants; low-quality evidence). The pooled MD of -2.86 did not reach the SGRQ minimal clinically important difference (MCID) of four points. Self-management intervention participants were also at a slightly lower risk for at least one respiratory-related hospital admission (odds ratio (OR) 0.75, 95% CI 0.57 to 0.98; 15 studies, 3263 participants; very low-quality evidence). The number needed to treat to prevent one respiratory-related hospital admission over a mean of 9.75 months' follow-up was 15 (95% CI 8 to 399) for participants with high baseline risk and 26 (95% CI 15 to 677) for participants with low baseline risk. No differences were observed in respiratory-related mortality (risk difference (RD) 0.01, 95% CI -0.02 to 0.04; 8 studies, 1572 participants; low-quality evidence) and all-cause mortality (RD -0.01, 95% CI -0.03 to 0.01; 24 studies, 5719 participants; low-quality evidence). We graded the evidence to be of ‘moderate’ to ‘very low’ quality according to GRADE. All studies had a substantial risk of bias, because of lack of blinding of participants and personnel to the interventions, which is inherently impossible in a self-management intervention. In addition, risk of bias was noticeably increased because of insufficient information regarding a) non-protocol interventions, and b) analyses to estimate the effect of adhering to interventions. Consequently, the highest GRADE evidence score that could be obtained by studies was ‘moderate’. Authors' conclusions: Self-management interventions for people with COPD are associated with improvements in HRQoL, as measured with the SGRQ, and a lower probability of respiratory-related hospital admissions. No excess respiratory-related and all-cause mortality risks were observed, which strengthens the view that COPD self-management interventions are unlikely to cause harm. By using stricter inclusion criteria, we decreased heterogeneity in studies, but also reduced the number of included studies and therefore our capacity to conduct subgroup analyses. Data were therefore still insufficient to reach clear conclusions about effective (intervention) characteristics of COPD self-management interventions. As tailoring of COPD self-management interventions to individuals is desirable, heterogeneity is and will likely remain present in self-management interventions. For future studies, we would urge using only COPD self-management interventions that include iterative interactions between participants and healthcare professionals who are competent using behavioural change techniques (BCTs) to elicit participants' motivation, confidence and competence to positively adapt their health behaviour(s) and develop skills to better manage their disease. In addition, to inform further subgroup and meta-regression analyses and to provide stronger conclusions regarding effective COPD self-management interventions, there is a need for more homogeneity in outcome measures. More attention should be paid to behavioural outcome measures and to providing more detailed, uniform and transparently reported data on self-management intervention components and BCTs. Assessment of outcomes over the long term is also recommended to capture changes in people's behaviour. Finally, information regarding non-protocol interventions as well as analyses to estimate the effect of adhering to interventions should be included to increase the quality of evidence.
UR - http://www.scopus.com/inward/record.url?scp=85122749882&partnerID=8YFLogxK
U2 - 10.1002/14651858.CD002990.pub4
DO - 10.1002/14651858.CD002990.pub4
M3 - Review article
C2 - 35001366
AN - SCOPUS:85122749882
SN - 1361-6137
JO - Cochrane database of systematic reviews (CD-ROM)
JF - Cochrane database of systematic reviews (CD-ROM)
IS - 1
M1 - CD002990
ER -