Supported self-management for patients with COPD who have recently been discharged from hospital: a systematic review and meta-analysis

Abstract

Purpose

Although many hospitals promote self-management to chronic obstructive pulmonary disease (COPD) patients post discharge from hospital, the clinical effectiveness of this is unknown. We undertook a systematic review of the evidence as part of a Health Technology Assessment review.

Methods

A comprehensive search strategy with no language restrictions was conducted across relevant databases from inception to May 2012. Randomized controlled trials of patients with COPD, recently discharged from hospital after an acute exacerbation and comparing a self-management intervention with control, usual care or other intervention were included. Study selection, data extraction, and risk of bias assessment were undertaken by two reviewers independently.

Results

Of 13,559 citations, 836 full texts were reviewed with nine randomized controlled trials finally included in quantitative syntheses. Interventions were heterogeneous. Five trials assessed highly supported multi-component interventions and four trials were less supported with fewer contacts with health care professionals and mainly home-based interventions. Total sample size was 1,466 (range 33–464 per trial) with length of follow-up 2–12 months. Trials varied in quality; poor patient follow-up and poor reporting was common. No evidence of effect in favor of self-management support was observed for all-cause mortality (pooled hazard ratio =1.07; 95% confidence interval [0.74 to 1.55]; I²=0.0%, [n=5 trials]). No clear evidence of effect on all-cause hospital admissions was observed (hazard ratio 0.88 [0.61, 1.27] I²=66.0%). Improvements in St George’s Respiratory Questionnaire score were seen in favor of self-management interventions (mean difference =3.84 [1.29 to 6.40]; I²=14.6%), although patient follow-up rates were low.

Conclusion

There is insufficient evidence to support self-management interventions post-discharge. There is a need for good quality primary research to identify effective approaches.

Keywords:

• chronic obstructive pulmonary disease
• self-management support
• post-discharge
• systematic review

Acknowledgments

The authors thank the following: Simon Stevens for his invaluable administrative support and the people who kindly gave their time to help translate articles: Yumiko Akiya, Dom Barkos, Susan Bayliss, Matthew Blackburn, Yumi Chen, Jennifer Choi, Karin Diaconu, Janine Dretzke, Maxwell Feltham, Ditte Hedegaard, Boris Kysela, Antje Lindenmeyer, Kinga Malottki, Cristina Peñaloza, Amanda Zhang.

Funding

National Institute for Health Research (NIHR) Health Technology Assessment Programme (10/44/01). Rachel E Jordan was also funded by the NIHR with a post-doctoral research fellowship (pdf/01/2008/023). Kate Jolly is part-funded by the NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRC) West Midlands. Sally J Singh is part-funded by the Collaboration for Leadership in Applied Health Research and Care East Midlands (CLAHRC EM). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health. Any errors are the responsibility of the authors.

Disclosure

Dr Price reports grants from UK Medical Research Council, during the conduct of the study; Dr Turner reports grants from University of Birmingham/NIHR, during the conduct of the study; Dr Jordan, Prof Jolly, Prof Adab, Prof Fitzmaurice, and Dr Moore report grants from the NIHR, during the conduct of the study; Prof Singh reports that the University Hospitals of Leicester NHS trust holds the intellectual property for a self management manual for COPD and reports a British Lung Foundation grant for RCT of self-management support post admission. The authors report no other conflicts of interest.

Publications

This paper is derived from a larger HTA evidence synthesis report (in press). Part of these data have been presented at the International Primary Care Respiratory Group conference in Stockholm (May 2013) and the British Thoracic Society conference in London (November 2013).

Author contributions

REJ and KJ led the development of the protocol and directed the review. SB undertook the searching. SM led the selection of studies with assistance from NRH, AMT, DJM, DAF, KJ, REJ and RJ, SM, MJP, NRH, undertook data extraction and evaluation. MJP undertook the statistical analysis with advice from RDR. All authors contributed towards review decision making, data analysis, drafting and revising the manuscript.