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QUESTION: In patients with chronic obstructive pulmonary disease (COPD), does a COPD specific self management programme reduce hospital use and improve health status more than usual care?
Design
Randomised (allocation concealed), blinded {data collectors and data analysts}*, controlled trial with 12 months of follow up.
Setting
7 hospitals in 3 cities in Quebec, Canada.
Patients
191 patients ≥50 years of age (mean age 70 y, 55% men) who had stable COPD (respiratory symptoms and medication unchanged for ≥4 wks); were current or previous smokers; had an FEV1 25–70% of predicted and an FEV1 forced vital capacity ratio <70%; no previous asthma, left congestive heart failure, terminal disease, dementia, or uncontrolled psychiatric illness; had not been in a respiratory rehabilitation programme in the previous year; and had no long term care facility stays. 86% of patients completed the 12 month assessment.
Intervention
Patients were stratified by centre. 96 patients were allocated to a self management programme (“Living Well with COPD,” Boehringer Ingelheim Canada) delivered by case managers (nurses, respiratory therapists, and a physiotherapist) for 1 hour per week in the patient’s home for 7–8 weeks. The programme included 7 educational modules on COPD, a customised action plan for acute exacerbations linked with therapeutic actions (including a prescription for an antibiotic and oral corticosteroid to be initiated promptly for exacerbations characterised by specific symptoms), case manager availability by telephone, and exercise programme instruction (warm up and stretching, muscle, and cardiovascular exercises to be done ≥3 times/wk for 30–45 min/session). 95 patients were allocated to usual care (management by treating physician, free healthcare services, and drug benefit plan)
Main outcome measures
Hospital admission (acute hospital stay of any duration, day hospital stay ≥8 h for 2 consecutive d, or emergency department [ED] visit requiring ≥24 h of care). Secondary outcomes included unscheduled physician and ED visits.
Main results
Analysis was by intention to treat. 299 acute exacerbations occurred in the self management group and 362 in the usual care group. Patients in the self management group had fewer admissions for acute exacerbations (71 v 118 admissions, p=0.01), fewer ED visits for acute exacerbations (95 v 161 visits, p=0.02), and fewer unscheduled visits to their family physician (46 v 112 visits, p=0.003). Fewer patients in the self management group had ≥1 admission for acute exacerbation or ≥1 ED visit for acute exacerbation (table⇓).
Disease specific self management v usual care for acute exacerbations (AEs) of chronic obstructive pulmonary disease†
Conclusion
A COPD specific self management programme reduced hospital use and improved health status more than usual care.
Commentary
Current approaches to self management education for COPD in clinical practice are diverse, varying from providing printed materials to individualised teaching sessions to convey information, and group workshops to teach patients specific skills. The study by Bourbeau et al assessed a multifaceted self management intervention, which comprised individual education, skills training, self help workbooks, and supportive telephone calls. Although the self management intervention did not improve lung function or exercise capacity, exacerbations, hospital admissions, and use of other healthcare facilities were reduced.
The needs of patients with COPD and their families are recognised in the guidelines of the Global Initiative for Chronic Obstructive Lung Disease,1 which highlight the importance of patients understanding the nature of the disease, risk factors for progression, and the role of healthcare providers in achieving optimal management and health outcomes. The guidelines also suggest that education should be tailored to the needs and environment of individual patients.
A recent meta-analysis concluded that insufficient data were available to recommend self management education for patients with COPD.2 The review identified a limited number of studies, which included a broad spectrum of interventions and outcomes.
It would be useful to compare this self management programme with disease specific counselling to determine whether the education or support components were responsible for the beneficial effects. Also, it would be useful to assess the effects on behaviours such as smoking cessation and compliance with drug therapy, as these could help explain reasons underlying improvements in health status.
Although this intervention may save money by reducing exacerbations and use of healthcare resources, improvements in health status that are important to patients should also be considered.
Footnotes
↵* Information provided by author.
Sources of funding: Boehringer Ingelheim Canada and Fonds de la Recherche en Santé du Québec.
For correspondence: Dr J Bourbeau, Montreal Chest Institute of the Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada. jean.bourbeau{at}mcgill.ca
A modified version of this abstract appears in ACP Journal Club.