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Original Research: COPD |

Self-Management Following an Acute Exacerbation of COPDSelf-Management After an Acute COPD Exacerbation: A Systematic Review FREE TO VIEW

Samantha L. Harrison, PhD; Tania Janaudis-Ferreira, PhD; Dina Brooks, PhD; Laura Desveaux, MSc; Roger S. Goldstein, MD, FCCP
Author and Funding Information

From the Department of Respiratory Medicine (Drs Harrison, Janaudis-Ferreira, Brooks, and Goldstein and Ms Desveaux), West Park Healthcare Centre; and Department of Physical Therapy (Drs Janaudis-Ferreira, Brooks, and Goldstein and Ms Desveaux) and Department of Medicine (Dr Goldstein), University of Toronto, Toronto, ON, Canada.

CORRESPONDENCE TO: Samantha L. Harrison, PhD, Department of Respiratory Medicine, West Park Healthcare Centre, 82 Buttonwood Ave, Toronto, ON, M6M2J5, Canada; e-mail: samantha.harrison@westpark.org


Drs Harrison and Janaudis-Ferreira share joint first authorship.

FUNDING/SUPPORT: Dr Brooks holds a Canada research chair.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(3):646-661. doi:10.1378/chest.14-1658
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Published online

BACKGROUND:  Self-management (SM) reduces hospital admissions in patients with stable COPD. However, its role immediately post-acute exacerbation (AE) is unclear. The objectives of this review were to describe SM interventions delivered immediately following an AE of COPD (AECOPD) and to conduct a systematic review with meta-analysis of its impact on health-care utilization and health outcomes.

METHODS:  Randomized controlled trials reporting on SM interventions delivered during hospitalization for an AECOPD or within 1 month of hospital discharge were included. Seven articles were identified. Data were extracted and assessed for quality by two researchers.

RESULTS:  By definition, all interventions included action plans, education, and at least two SM skills. Nurses were responsible for providing all SM interventions. The delivery and follow-up periods varied widely. At 12 months, there were no significant differences between those who completed the SM intervention and control subjects in the number of patients readmitted to hospital (P = .38), or in health-related quality of life (P = .27). No effects were found on rate of mortality, depressive symptoms, primary care usage, or exercise capacity. Minimal effects were found on self-efficacy, anxiety symptoms, and health promoting behavior. SM was associated with positive effects on knowledge and management of an AECOPD.

CONCLUSIONS:  SM interventions delivered immediately post-AE vary widely and outcome measures are inconsistent, making it difficult to draw strong recommendations regarding its effectiveness. The evaluation of SM interventions, delivered by trained health-care professionals to selected patients and which offer structured follow-up, appears necessary.

Figures in this Article

Self-management (SM) describes formalized patient education programs aimed at teaching skills and providing support for health-promoting behavior.1 It has been cited as a strategy for reducing hospital admissions in patients with stable COPD2,3 by assisting with the prompt recognition and management of acute exacerbations (AEs).4,5 A recently updated Cochrane review found that SM in the absence of supervised exercise was effective in reducing respiratory-related and all-cause hospital admissions and improving health-related quality of life (HRQOL) in patients with COPD.3 In this review, SM was delivered to patients with stable disease or those up to 12 months post-AE. Only one study delivered SM to all patients immediately following an AE of COPD (AECOPD).6

The role of SM alone delivered immediately post-AE is not clear.7 At the time of hospital admission, patients may be more receptive to interventions that improve their health, especially if they believe that such interventions may reduce subsequent hospital admissions. Behavioral interventions, such as smoking cessation, initiated during hospitalization have been proven to be effective.8 However, breathlessness, anxiety, and vigilance of symptoms may inhibit patients from attending to the information being provided,9,10 especially in the presence of hypoxemia shown to compromise attention and cognitive function.11

The aim of this systematic review was to examine the effects of SM alone delivered during hospitalization for an AECOPD or within 1 month of hospital discharge. A definition adopted from Wagg12 was modified to include interventions which have delivered an action plan, education, and at least two of seven SM skills: self-efficacy, problem solving, resource utilization, collaboration, emotional management, role management, and goal setting. Interventions that included supervised exercise programs were not considered to be SM.12 The specific study objectives were (1) to describe SM interventions delivered immediately following an AECOPD and (2) to conduct a systematic review with meta-analysis of their impact on health-care utilization and health outcomes. Such information may help to guide health-care professionals (HCPs) in the delivery of SM advice to patients following hospitalization with an AECOPD.

Search Strategy

The set of terms included: “chronic obstructive” OR COPD OR emphysema OR bronchitis AND exacerbat* OR hospital* AND education OR self-manag* OR “self manag” OR self-care* OR “self car*” OR “management plan” OR “management prog*” OR “action plan” OR “integrated care”. An extensive search was conducted in August 2013, and updated in March 2014, of electronic databases including PubMed, AMED, CINAHL, British Nursing Index (BNI), PsychINFO, EMBASE, and MEDLINE from inception to present. The reference lists of key papers were searched to identify any further relevant studies.

Selection of Articles

The review was restricted to randomized controlled trials (RCTs) consisting of SM intervention vs usual care, published in English in peer-reviewed journals. To be included, papers had to report on SM interventions delivered during hospitalization for an AECOPD or within 1 month of hospital discharge. To be accepted as SM, interventions had to include an action plan involving symptom monitoring and medical management as well as education providing knowledge and information on decision-making.12 The definition of SM provided by Wagg12 is slightly adjusted to include interventions that have delivered at least two of seven SM skills: self-efficacy, problem solving, resource utilization, collaboration, emotional management, role management, and goal setting. In instances where it was unclear whether either disease education or action plans were included, the authors were contacted. Interventions describing solely action plans or action plans with education were excluded, as were disease management programs including supervised exercise training or programs that could be classified as pulmonary rehabilitation. Studies that enrolled clinically stable patients or those in which the time between hospital discharge and initiation of the intervention could not be determined for all study participants were excluded.

Screening:

One reviewer (S. L. H.) screened the titles and abstracts. In instances where the first reviewer was unsure, the abstracts were discussed with a second reviewer (T. J.-F.) and a consensus reached.

Two reviewers (S. L. H. and T. J.-F.) assessed the appropriateness of the full text papers against the inclusion and exclusion criteria. Papers categorized as unsure were discussed between reviewers and also at a meeting with the senior authors (D. B. and R. S. G.).

Determination of Study Quality

Full text papers were assessed for quality using the Cochrane Collaboration Tool.13 Each study was assessed independently by two reviewers (S. L. H. and T. J.-F.), and any discrepancies were discussed to reach consensus.

Data Extraction

Data extraction was performed and verified by two reviewers (S. L. H. and T. J.-F.). There were two objectives as follows: (1) All information describing the SM intervention was extracted. (2) The results of the studies were summarized according to the effect of the SM intervention on all included health outcomes.

Meta-analysis

A meta-analysis exploring the impact of SM interventions was conducted for those outcomes which were assessed in three or more studies, these included health-care utilization and HRQOL. Heterogeneity was investigated according to the guidelines in the Cochrane Handbook for Systematic Reviews, and involved examining the overlap in CIs, interpreting the χ2 test, and the I2 statistic.14 Due to the heterogeneity of the SM interventions, random models were applied in both cases.

Identification of Papers

All papers were identified during the first search in August 2013. An updated search using the same search terms and databases did not identify any new papers. The initial database produced 2,683 titles and abstracts; after duplicates were removed, 1,106 remained: of these, 1,088 articles were excluded during the initial screening. Full text was obtained for 18 papers, of which 11 studies were excluded following appraisal with reasons for exclusion documented in Figure 1.1525 Seven articles were included in total. The SM skills identified for the included studies are documented in Table 1. Two studies applied the same intervention but the outcomes assessed differed, therefore, both papers were included in the review.6,26

Figure Jump LinkFigure 1 –  PRISMA flowchart. AE = acute exacerbation; RCT = randomized controlled trial; SM = self-management.Grahic Jump Location
Table Graphic Jump Location
TABLE 1 ]  Evidence of SM for the Included Studies and Those Studies Excluded for Not Meeting the Criteria for SM

AE = acute exacerbation; SM = self-management.

Description of SM Interventions

A full description of the delivery and structure of each SM intervention is displayed in Table 2. Six interventions are described in the seven studies.6,26 The setting for delivering SM interventions varied with two interventions being delivered in-hospital6,26,27 and the remainder within 1 month of hospital discharge. Five interventions included at least one face-to-face follow-up visit with other consultations conducted over the phone while one intervention included telephone consultations only. The length of continued support ranged from 2 to 3 weeks to 12 months. All programs were delivered by nurses, although one intervention included a home visit consisting of a specialized nurse and the primary care team (physician, nurse, and social worker).26 In four programs, nurses were specialized or had received specific training.6,26,2830 Education topics commonly included COPD education, smoking cessation, medical management, stress management/relaxation, and the promotion of physical activity as well as exercise. The most commonly applied SM skills were problem solving, role management, resource utilization, collaboration, and goal setting. Strategies to teach SM skills for coping with future AECOPD were only specifically described in one intervention.6,26

Table Graphic Jump Location
TABLE 2 ]  The Delivery and Structure of SM Delivered Immediately Following Hospitalization With an AECOPD

6MWD = 6-min walk test; AECOPD = acute exacerbation of COPD; COPD-SEQ = COPD-self-efficacy questionnaire; CSES = Chinese self-efficacy scale; DC = discharge; EQOL-5D = EuroQol-5D; FU = follow-up; GP = general practitioner; HADS = Hospital Anxiety and Depression Scale; HCP = health-care professional; HRQOL = health-related quality of life; IAS = inhaler adherence scale; MAS = medication adherence scale; SF-36 = Short Form 36; SGRQ = St. George’s Respiratory Questionnaire; SSEQ = Stanford self-efficacy questionnaire. See Table 1 legend for expansion of other abbreviations.

Systematic Review With Meta-analysis
Study Quality and Outcomes:

Overall, the risk of bias for the majority of RCTs was low; however, frequent issues included no blinding of participants and underreporting of reasons for withdrawal. An overview of the quality assessment is displayed in Table 3. Study outcomes are summarized in Table 4.

Table Graphic Jump Location
TABLE 3 ]  Cochrane Collaboration Tool for Assessing Risk of Bias

Review author’s judgment assessed as low, unclear, or high risk of bias. High = bias of sufficient magnitude to have a notable effect on the results or conclusions of the trial; Low = no obvious risk of bias; Unclear = insufficient detail is reported of what happened in the trial.

Table Graphic Jump Location
TABLE 4 ]  Outcomes of SM Delivered Following Hospitalization With an AECOPD

Anx = anxiety; Dep = depression; NBGD = no between-group differences; + = positive result. See Table 1 and 2 legends for expansion of other abbreviations.

Hospital Admissions:

Admission to hospital was assessed in five studies. Self-reported admissions to hospital were reported in two,29,31 while three studies examined clinical records to verify hospital admission.6,28,30

Only one study found significant differences in favor of those receiving the SM intervention (P = .03),6 while three identified no differences (P > .05).2931 Additionally, one study compared those classified as a successful self-manager (prompt responders) to those who were deemed unsuccessful (a two-point deterioration for 2 consecutive days before commencing treatment).28 A significant within-group reduction was noted in the number of patients admitted to hospital for those classified as successful self-managers (P < .001), although overall no between-group differences emerged (P = .73).

Results of the meta-analysis revealed that, at 12 months, there were no significant differences in the number of patients readmitted to hospital following an AECOPD (mean difference [MD] = 1.32; 95% CI, 0.71-2.46; P = .38)6,28,30 (Fig 2).

Figure Jump LinkFigure 2 –  Results for the meta-analysis on hospital admissions. df = degrees of freedom; M-H = Mantel-Haenszel.Grahic Jump Location
Health-Related Quality of Life:

Four studies examined differences in HRQOL following completion of SM intervention compared with those receiving usual care using either the St. George’s Respiratory Questionnaire (SGRQ)26,28,31 or the Short Form-36 (SF-36).30 No between-group differences were noted in overall HRQOL. There were between-group differences in the SF-36 subscales for physical functioning (P = .01) and general health (P = .05)30 and for the SGRQ impact subscale (P < .015)28 in favor of SM intervention.

The meta-analysis showed that there were no significant differences in total scores of HRQOL across the four studies (standardized mean difference = 0.11; 95% CI, −0.08-0.36; P = .27) (Fig 3). Analysis of individual domains of the SGRQ did not reveal significant differences (symptoms [MD = 1.10; 95% CI, −3.83 to 6.02; P = .66]; activities [MD = −1.46; 95% CI, −4.43 to 1.51; P = .33]; impacts [MD = 3.48; 95% CI, −1.24 to 8.20, P = .15]).

Figure Jump LinkFigure 3 –  Results for the meta-analysis on health-related quality of life (total score). Std = standardized. See Table 2 legend for expansion of other abbreviations.Grahic Jump Location
Mortality:

Two studies reported the percentage of patients who died during the study period.6,28 No differences were detected between the intervention and control group for all-cause mortality (P = .67),6 (P = .30),28 or COPD-specific deaths (P = .35).29

Knowledge:

Two studies assessed the impact of SM intervention on patient knowledge using nonstandardized tools.26,31 Those who completed SM intervention had greater knowledge compared with those receiving only usual care (P < .05).26,31

Self-Efficacy:

Three studies examined the effectiveness of SM intervention on self-efficacy.2830 One study identified a significant difference in self-efficacy between the intervention and control groups (P = .0329), while the other two studies identified no differences (P = .54,28P = .6830).

Psychologic Morbidity:

Anxiety and depression were explored in two of the six studies.28,30 One study found less anxiety scores following SM intervention compared with a control group (P < .044) although there was no difference in depression scores (P > .538).28 The other study identified no differences in anxiety or depression.30

Primary Care Visits:

Three studies examined the effect of SM intervention on the use of primary care services compared with a control group and found no differences (P = 1.00),29 (P = .44 and P = .45 for Barcelona and Leuven sites, respectively),6 (P = .30 for patient reported and P = .90 for general practitioner reported).31

SM of an AECOPD:

One study identified significant differences in the identification (P < .001) and early treatment of an exacerbation (P = .04). Results favored the SM intervention group.26

Positive Health Behavior Change:

Health-promoting behavior included any of the following: smoking habits, alcohol habits, medication adherence, exercise behavior, and physical activity. Three studies assessed aspects of health-promoting behavior26,27,31 with two reporting no significant differences.26,27,31 Increased exercise behavior and medication adherence were observed in one study in patients who completed SM intervention compared with usual care (P < .001 and P = .05, respectively).27

Exercise Capacity:

Only one study assessed exercise capacity. No between-group differences were identified (P = .42).27

This is the first systematic review examining the effect of SM interventions, in the absence of supervised exercise, delivered immediately post-AECOPD. The SM interventions included in the studies were delivered in-hospital and in patients’ homes by nurses. All studies included action plans for the early recognition of AE, as well as disease-specific education, but strategies to teach SM skills were limited. The health outcomes assessed varied widely across studies, often in the absence of standardized, objective measures. Findings revealed that SM alone delivered immediately post-AECOPD did not impact on hospital readmissions or HRQOL. No effects were found on rate of mortality, depressive symptoms, primary care usage, or exercise capacity. Minimal effects were found on self-efficacy, anxiety symptoms, and health-promoting behavior. SM was associated with positive effects on knowledge26,31 and management of an AECOPD.26

The absence of effect on hospital readmission of SM delivered immediately following an AECOPD contrasts with evidence from patients with stable disease.2,3 A recent Cochrane review identified that SM interventions are effective in reducing respiratory-specific and all-cause hospital admissions.3 It was not possible in this review to divide respiratory and all-cause admissions. Similarly, the absence of effect on HRQOL contrasts with the positive impact observed when SM interventions are provided for stable patients with COPD.3 Following an AECOPD, patients may be unwilling or unable to comply with SM advice. Patients’ engagement in active interventions, such as rehabilitation, post-AE has been shown to be poor.32,33 Furthermore, patients’ ability to attend to new information when they are acutely breathless may be compromised.11

Although studies were selected based on their inclusion of two or more SM strategies, shortcomings in the delivery of SM interventions included little emphasis on teaching and empowering patients to use SM skills, with only two studies reporting training nurses in the principles of behavior change theories and interventions.28,30 Fewer than 50% of patients who received SM intervention post-AE were classified as successfully mastering SM skills,28 and for these individuals, the likelihood of readmission to hospital was improved. Second, despite heightened levels of distress post-AECOPD,10 there has been little attention given to patients’ psychologic status. This may be important when considering patients’ suitability for enrollment in SM interventions as distress and body vigilance increase following SM intervention in patients who post-AE were identified as suffering from panic disorder.34 Finally, only one intervention included more than two home visits and maintained face-to-face follow-up for 12 months.28 Interestingly, this study demonstrated the greatest improvements in social and psychologic functioning. It may be necessary to reinforce information at a time when acute breathlessness has resolved and patients’ ability to attend to information has improved.

Despite the questionable effectiveness of SM interventions post-AE, the safety of such interventions appears to be acceptable, with two studies reporting no differences in mortality between groups. This is a relevant observation since the safety of delivering SM post-AE has been recently questioned with higher mortality rates evident in those who participated in SM intervention post-AE.35 SM interventions may not be appropriate for all patients and identifying those in whom it might be effective is necessary.

This review presents a number of limitations which ought to be considered. As SM has multiple components, issues of study heterogeneity are not surprising. Information on specific components of the intervention is limited; specifically, in most studies, action plans, which are an important component of SM, are poorly described, information is not provided on the intent vs actual delivery of the intervention and little detail is offered on the type of behavior the intervention is aiming to change. Alterations in “usual care” over the time period of the studies, from discharge with no support29,31 to education and management as part of standardized care,27 may also have affected the observed impact of a SM intervention. Few studies assessed knowledge, although standardized, valid, and reliable disease-specific tools are available.36 The outcomes assessed were not always matched to the content of the interventions. For example, studies assessed anxiety and depression but SM interventions did not address psychological symptoms. Issues with bias were identified across all seven included studies with SM interventions being delivered only to those without any impairment of cognitive functioning. Given the prevalence of cognitive impairment in patients with COPD (27%), the generalizability of results is limited.37 A final limitation of the review pertains to the involvement of one reviewer in the initial screening of articles, although two reviewers (S. L. H. and T. J.-F.) worked in close collaboration and several meetings were held with the senior authors (D. B. and R. S. G.) throughout the selection process.

Future research is required to establish the potential importance of training HCPs in theories of behavior change and the delivery of SM skills as well as understanding the impact of the level of expertise (general nurse vs specialized nurse). Given the heterogeneity of the studies reviewed, it is difficult to evaluate the effectiveness of SM intervention delivered immediately post-AE. Although, to date, SM delivered immediately post-AE appears to have limited effectiveness, particularly in addressing readmissions and improving HRQOL, the trials which do demonstrate some success include structured follow-up. This follow-up should be individualized, focused on reinforcing SM skills, and offer face-to-face contact.

In conclusion, the content of SM interventions delivered immediately post-AE and the health outcomes assessed vary widely, as with studies in stable patients with COPD, making it difficult to conclude that there is any evidence for its effectiveness.

Author contributions: R. G. is the guarantor of the manuscript and takes responsibility for the integrity of the data and the accuracy of the data analysis. S. L. H. and T. J.-F. contributed to study conception and design, searched literature, extracted and interpreted data, wrote the manuscript, and approved the final version of the manuscript; D. B. and R. S. G. contributed to study conception and design, interpreted data, provided critical revisions that were important for intellectual content, and approved the final version of the manuscript; and L. D. contributed to data interpretation, provided critical revisions that were important for intellectual content, and approved the final version of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

Other contributions: Sally Singh, PhD, reviewed the final manuscript.

AE

acute exacerbation

AECOPD

acute exacerbation of COPD

HCP

health-care professional

HRQOL

health-related quality of life

MD

mean difference

RCT

randomized controlled trial

SF-36

Short Form-36

SGRQ

St. George’s Respiratory Questionnaire

SM

self-management

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Figures

Figure Jump LinkFigure 1 –  PRISMA flowchart. AE = acute exacerbation; RCT = randomized controlled trial; SM = self-management.Grahic Jump Location
Figure Jump LinkFigure 2 –  Results for the meta-analysis on hospital admissions. df = degrees of freedom; M-H = Mantel-Haenszel.Grahic Jump Location
Figure Jump LinkFigure 3 –  Results for the meta-analysis on health-related quality of life (total score). Std = standardized. See Table 2 legend for expansion of other abbreviations.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Evidence of SM for the Included Studies and Those Studies Excluded for Not Meeting the Criteria for SM

AE = acute exacerbation; SM = self-management.

Table Graphic Jump Location
TABLE 2 ]  The Delivery and Structure of SM Delivered Immediately Following Hospitalization With an AECOPD

6MWD = 6-min walk test; AECOPD = acute exacerbation of COPD; COPD-SEQ = COPD-self-efficacy questionnaire; CSES = Chinese self-efficacy scale; DC = discharge; EQOL-5D = EuroQol-5D; FU = follow-up; GP = general practitioner; HADS = Hospital Anxiety and Depression Scale; HCP = health-care professional; HRQOL = health-related quality of life; IAS = inhaler adherence scale; MAS = medication adherence scale; SF-36 = Short Form 36; SGRQ = St. George’s Respiratory Questionnaire; SSEQ = Stanford self-efficacy questionnaire. See Table 1 legend for expansion of other abbreviations.

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TABLE 3 ]  Cochrane Collaboration Tool for Assessing Risk of Bias

Review author’s judgment assessed as low, unclear, or high risk of bias. High = bias of sufficient magnitude to have a notable effect on the results or conclusions of the trial; Low = no obvious risk of bias; Unclear = insufficient detail is reported of what happened in the trial.

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TABLE 4 ]  Outcomes of SM Delivered Following Hospitalization With an AECOPD

Anx = anxiety; Dep = depression; NBGD = no between-group differences; + = positive result. See Table 1 and 2 legends for expansion of other abbreviations.

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