This paper describes developments in the fields of asthma and COPD self-management interventions (SMIs) over the last two decades and discusses future directions. Evidence around SMIs has ...exponentially grown. Efficacy on group level is convincing and both asthma and COPD SMIs are currently recommended by respiratory guidelines. Core components of asthma SMIs are defined as education, action plans, and regular review, with some discussion about self-monitoring. Exacerbation action plans are defined as an integral part of COPD management. Patient’s adherence to SMI’s is however inadequate and significantly reducing the intervention’s impact. Adherence could be improved by tailoring of SMIs to patients’ needs, health beliefs, and capabilities; the use of shared decision making; and optimising the communication between patients and health care providers. Due to the COVID-19 pandemic, digital health innovations have rapidly been introduced and expanded. Digital technology use may increase efficiency, flexibility, and efficacy of SMIs. Furthermore, artificial intelligence can be used to e.g., predict exacerbations in action plans. Research around digital health innovations to ensure evidence-based practice is of utmost importance. Current implementation of respiratory SMIs is not satisfactory. Implementation research should be used to generate further insights, with cost-effectiveness, policy (makers), and funding being significant determinants.
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.
Background
Chronic Obstructive Pulmonary Disease (COPD) self‐management interventions should be structured but personalised and often multi‐component, with goals of motivating, engaging and ...supporting the patients to positively adapt their behaviour(s) and develop skills to better manage disease. Exacerbation action plans are considered to be a key component of COPD self‐management interventions. Studies assessing these interventions show contradictory results. In this Cochrane Review, we compared the effectiveness of COPD self‐management interventions that include action plans for acute exacerbations of COPD (AECOPD) with usual care.
Objectives
To evaluate the efficacy of COPD‐specific self‐management interventions that include an action plan for exacerbations of COPD compared with usual care in terms of health‐related quality of life, respiratory‐related hospital admissions and other health outcomes.
Search methods
We searched the Cochrane Airways Group Specialised Register of trials, trials registries, and the reference lists of included studies to May 2016.
Selection criteria
We included randomised controlled trials evaluating a self‐management intervention for people with COPD published since 1995. To be eligible for inclusion, the self‐management intervention included a written action plan for AECOPD and an iterative process between participant and healthcare provider(s) in which feedback was provided. We excluded disease management programmes classified as pulmonary rehabilitation or exercise classes offered in a hospital, at a rehabilitation centre, or in a community‐based setting to avoid overlap with pulmonary rehabilitation as much as possible.
Data collection and analysis
Two review authors independently assessed trial quality and extracted data. We resolved disagreements by reaching consensus or by involving a third review author. Study authors were contacted to obtain additional information and missing outcome data where possible. When appropriate, study results were pooled using a random‐effects modelling meta‐analysis. The primary outcomes of the review were health‐related quality of life (HRQoL) and number of respiratory‐related hospital admissions.
Main results
We included 22 studies that involved 3,854 participants with COPD. The studies compared the effectiveness of COPD self‐management interventions that included an action plan for AECOPD with usual care. The follow‐up time ranged from two to 24 months and the content of the interventions was diverse.
Over 12 months, there was a statistically significant beneficial effect of self‐management interventions with action plans on HRQoL, as measured by the St. George's Respiratory Questionnaire (SGRQ) total score, where a lower score represents better HRQoL. We found a mean difference from usual care of ‐2.69 points (95% CI ‐4.49 to ‐0.90; 1,582 participants; 10 studies; high‐quality evidence). Intervention participants were at a statistically significant lower risk for at least one respiratory‐related hospital admission compared with participants who received usual care (OR 0.69, 95% CI 0.51 to 0.94; 3,157 participants; 14 studies; moderate‐quality evidence). The number needed to treat to prevent one respiratory‐related hospital admission over one year was 12 (95% CI 7 to 69) for participants with high baseline risk and 17 (95% CI 11 to 93) for participants with low baseline risk (based on the seven studies with the highest and lowest baseline risk respectively).
There was no statistically significant difference in the probability of at least one all‐cause hospital admission in the self‐management intervention group compared to the usual care group (OR 0.74, 95% CI 0.54 to 1.03; 2467 participants; 14 studies; moderate‐quality evidence). Furthermore, we observed no statistically significant difference in the number of all‐cause hospitalisation days, emergency department visits, General Practitioner visits, and dyspnoea scores as measured by the (modified) Medical Research Council questionnaire for self‐management intervention participants compared to usual care participants. There was no statistically significant effect observed from self‐management on the number of COPD exacerbations and no difference in all‐cause mortality observed (RD 0.0019, 95% CI ‐0.0225 to 0.0263; 3296 participants; 16 studies; moderate‐quality evidence). Exploratory analysis showed a very small, but significantly higher respiratory‐related mortality rate in the self‐management intervention group compared to the usual care group (RD 0.028, 95% CI 0.0049 to 0.0511; 1219 participants; 7 studies; very low‐quality evidence).
Subgroup analyses showed significant improvements in HRQoL in self‐management interventions with a smoking cessation programme (MD ‐4.98, 95% CI ‐7.17 to ‐2.78) compared to studies without a smoking cessation programme (MD ‐1.33, 95% CI ‐2.94 to 0.27, test for subgroup differences: Chi² = 6.89, df = 1, P = 0.009, I² = 85.5%). The number of behavioural change techniques clusters integrated in the self‐management intervention, the duration of the intervention and adaptation of maintenance medication as part of the action plan did not affect HRQoL. Subgroup analyses did not detect any potential variables to explain differences in respiratory‐related hospital admissions among studies.
Authors' conclusions
Self‐management interventions that include a COPD exacerbation action plan are associated with improvements in HRQoL, as measured with the SGRQ, and lower probability of respiratory‐related hospital admissions. No excess all‐cause mortality risk was observed, but exploratory analysis showed a small, but significantly higher respiratory‐related mortality rate for self‐management compared to usual care.
For future studies, we would like to urge only using action plans together with self‐management interventions that meet the requirements of the most recent COPD self‐management intervention definition. To increase transparency, future study authors should provide more detailed information regarding interventions provided. This would help inform further subgroup analyses and increase the ability to provide stronger recommendations regarding effective self‐management interventions that include action plans for AECOPD. For safety reasons, COPD self‐management action plans should take into account comorbidities when used in the wider population of people with COPD who have comorbidities. Although we were unable to evaluate this strategy in this review, it can be expected to further increase the safety of self‐management interventions. We also advise to involve Data and Safety Monitoring Boards for future COPD self‐management studies.
This study explored whether, for people with chronic obstructive pulmonary disease (COPD), changes to the 24-hour composition of physical activity (PA), sedentary behaviour (SB) and sleep were ...associated with changes in symptoms and health-related quality of life (HRQoL); and how time re-allocations between these behaviours were associated with changes in outcomes.
This study pools data on people with COPD drawn from two previous studies: a randomised controlled trial of cognitive behavioural therapy and pulmonary rehabilitation and a usual care cohort. Participants recalled behaviours and completed symptom and HRQoL assessments at baseline (T0) and four months (T1). Linear mixed-effects models (pooled control/intervention samples) predicted changes in outcomes from T0 to T1 with a change to the 24-hour behaviour composition; compositional isotemporal substitution predicted change in outcomes when re-allocating time between behaviours.
Valid data were obtained for 95 participants (forced expiratory volume in one second %predicted = 49.6±15.3) at T0 and T1. A change in the 24-hour behaviour composition was associated with a change in anxiety (p<0.01) and mastery (p<0.01), but not breathlessness, depression or fatigue. When modelling time re-allocation with compositional isotemporal substitution, more time re-allocated to higher intensity PA or sleep was associated with favourable changes in outcomes; re-allocating time to SB or light PA was associated with unfavourable changes in outcomes. The direction of association, however, could not be determined.
To improve the overall health and wellbeing of people with COPD, intervention approaches that optimise the composition of PA, SB and sleep may be beneficial.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
There is an urgent need for consensus on what defines a chronic obstructive pulmonary disease (COPD) self-management intervention. We aimed to obtain consensus regarding the conceptual definition of ...a COPD self-management intervention by engaging an international panel of COPD self-management experts using Delphi technique features and an additional group meeting.In each consensus round the experts were asked to provide feedback on the proposed definition and to score their level of agreement (1=totally disagree; 5=totally agree). The information provided was used to modify the definition for the next consensus round. Thematic analysis was used for free text responses and descriptive statistics were used for agreement scores.In total, 28 experts participated. The consensus round response rate varied randomly over the five rounds (ranging from 48% (n=13) to 85% (n=23)), and mean definition agreement scores increased from 3.8 (round 1) to 4.8 (round 5) with an increasing percentage of experts allocating the highest score of 5 (round 1: 14% (n=3); round 5: 83% (n=19)).In this study we reached consensus regarding a conceptual definition of what should be a COPD self-management intervention, clarifying the requisites for such an intervention. Operationalisation of this conceptual definition in the near future will be an essential next step.
•38 % of the patients showed (sub)optimal adherence to COPD exacerbation action plans.•Multiple adherence categories provide detailed insight in patient’s action plan use.•Patient characteristics ...should be evaluated to shed light on non-adherence.•Dyspnoea and cardiac disease are potential predictors of lower patient adherence.
Identifying patient characteristics predicting categories of patient adherence to Chronic Obstructive Pulmonary Disease (COPD) exacerbation action plans.
Data were obtained from self-treatment intervention groups of two COPD self-management trials. Patients with ≥1 exacerbation and/or ≥1 self-initiated prednisolone course during one-year follow-up were included. Optimal treatment was defined as ‘self-initiating prednisolone treatment ≤2 days from the onset of a COPD exacerbation’. Predictors of adherence categories were identified by multinomial logistic regression analysis using patient characteristics.
145 COPD patients were included and allocated to four adherence categories: ‘optimal treatment’ (26.2 %), ‘sub optimal treatment’ (11.7 %), ‘significant delay or no treatment’ (31.7 %), or ‘treatment outside the actual exacerbation period’ (30.3 %). One unit increase in baseline dyspnoea score (mMRC scale 0–4) increased the risk of ‘significant delay or no treatment’ (OR 1.64 (95 % CI 1.07−2.50)). Cardiac comorbidity showed a borderline significant increased risk of ‘treatment outside the actual exacerbation period’ (OR 2.40 (95 % CI 0.98−5.85)).
More severe dyspnoea and cardiac comorbidity may lower adherence to COPD exacerbation action plans.
Tailored self-management support with more focus on dyspnoea and cardiac disease symptoms may help patients to better act upon increased exacerbation symptoms and improve adherence to COPD exacerbation action plans.
This international randomised controlled trial evaluated whether COPD patients with comorbidities, trained in using patient-tailored multidisease exacerbation action plans, had fewer COPD ...exacerbation days than usual care (UC).COPD patients (Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification II-IV) with ≥1 comorbidity (ischaemic heart disease, heart failure, diabetes, anxiety, depression) were randomised to a patient-tailored self-management intervention (n=102) or UC (n=99). Daily symptom diaries were completed for 12 months. The primary outcome "COPD exacerbation days per patient per year" was assessed using intention-to-treat analyses.No significant difference was observed in the number of COPD exacerbation days per patient per year (self-management: median 9.6 (interquartile range (IQR) 0.7-31.1); UC: median 15.6 (IQR 3.0-40.3); incidence rate ratio (IRR) 0.87 (95% CI 0.54; 1.39); p=0.546). There was a significantly shorter duration per COPD exacerbation for self-management (self-management: median 8.1 (IQR 4.8-10.1) days; UC: median 9.5 (IQR 7.0-15.1) days; p=0.021), with no between-group differences in the total number of respiratory hospitalisations (IRR 0.76 (95% CI 0.42; 1.35); p=0.348), but a lower probability of ≥1 for respiratory-related hospitalisation compared to UC (relative risk 0.55 (95% CI 0.35; 0.87); p=0.008). No between-group differences were observed in all-cause hospitalisations (IRR 1.07 (95% CI 0.66; 1.72)) or mortality (self-management: n=4 (3.9%); UC: n=7 (7.1%); relative risk 0.55 (95% CI 0.17; 1.84)).Patient-tailored exacerbation action plans for COPD patients with comorbidities did not significantly reduce exacerbation days, but reduced the duration per COPD exacerbation and the risk of having at least one respiratory-related hospitalisation during follow-up, without excess all-cause mortality.
In clinical practice, clinicians mainly focus on Chronic Obstructive Pulmonary Disease (COPD) exacerbations and symptoms, while patients may prefer to evaluate periods free of COPD exacerbations and ...deteriorated symptoms. The latter would suit the positive health approach that centralizes people and their beliefs. We aimed to identify patient characteristics and health outcomes relating to: 1) COPD exacerbation-free days; 2) days with no more symptoms than usual; and 3) combined COPD exacerbation and comorbid flare-up-free days (i.e. chronic heart failure, anxiety, depression flare-ups) using negative binomial regression analyzes. Data were obtained from two self-management intervention trials including COPD patients with and without comorbidities. 313 patients (mean age 66.0 years, 63.6% male, 68.7% comorbidity) were included. Better baseline chronic respiratory questionnaire (CRQ) fatigue (incidence rate ratio (IRR) = 1.03 (95% CI 1.01-1.05),
= 0.02) and mastery scores (IRR = 1.03 (95% CI 1.00-1.06),
= 0.04) and fewer courses of antibiotics (IRR = 0.95 (95% CI 0.94-0.96),
< 0.01) were related to more COPD exacerbation-free days. Additionally, better baseline CRQ fatigue (IRR = 1.05 (95% CI 1.00-1.10),
= 0.04) and mastery scores (IRR = 1.06 (95% CI 1.00-1.12),
= 0.04), fewer courses of antibiotics (IRR = 0.94 (95% CI 0.91-0.96),
< 0.01), and improved CRQ dyspnea scores over 12 months of follow-up (IRR = 1.07 (95% CI 1.01-1.12),
< 0.01) were correlated to more days free of deteriorated symptoms. Less baseline dyspnea (modified Medical Research Council score) (IRR = 0.95 (95% CI 0.92-0.98),
< 0.01) and fewer courses of antibiotics (IRR = 0.94 (95% CI 0.93-0.95),
< 0.01) were associated with more combined COPD exacerbation and comorbid flare-up-free days. Healthcare professionals should be aware that less fatigue and better mastering of COPD relate to more exacerbation and symptom-free time in COPD patients.
Objectives:
Physical activity, sedentary and sleep behaviours have strong associations with health. This systematic review aimed to identify how clinical practice guidelines (CPGs) for the management ...of chronic obstructive pulmonary disease (COPD) report specific recommendations and strategies for these movement behaviours.
Methods:
A systematic search of databases (Medline, Scopus, CiNAHL, EMbase, Clinical Guideline), reference lists and websites identified current versions of CPGs published since 2005. Specific recommendations and strategies concerning physical activity, sedentary behaviour and sleep were extracted verbatim. The proportions of CPGs providing specific recommendations and strategies were reported.
Results:
From 2370 citations identified, 35 CPGs were eligible for inclusion. Of these, 21 (60%) provided specific recommendations for physical activity, while none provided specific recommendations for sedentary behaviour or sleep. The most commonly suggested strategies to improve movement behaviours were encouragement from a healthcare provider (physical activity n = 20; sedentary behaviour n = 2) and referral for a diagnostic sleep study (sleep n = 4).
Conclusion:
Since optimal physical activity, sedentary behaviour and sleep durations and patterns are likely to be associated with mitigating the effects of COPD, as well as with general health and well-being, there is a need for further COPD-specific research, consensus and incorporation of recommendations and strategies into CPGs.
The prevalence of chronic obstructive pulmonary disease in Saudi Arabia is 4.2% among the general population and 14.2% among smokers. Studies showed that management of respiratory diseases is ...inadequate. In this article, we have elaborated on how factors as health economic factors, lack of health-care providers, culture, attitude, lifestyle (such as smoking and physical inactivity), and lack of adherence to the evidence-based practice guidelines may influence chronic respiratory disease management in Saudi Arabia. We have to conclude that these factors should be taken into account while seeking to improve and optimize the quality of care for patients with respiratory diseases in Saudi Arabia.
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