Do self-management interventions in COPD patients work and which patients benefit most? An individual patient data meta-analysis

Figures & data

Table 1 Baseline characteristics of COPD patients

Determinant	Categories	Control (n=1,492)	Intervention (n=1,790)	Total (N=3,282)
Sex	Male	999 (67.0)	1,151 (64.3)	2,150 (65.5)
	Female	492 (33.0)	639 (35.7)	1,131 (34.5)
Age	Mean (SD) years	68.3 (9.6)	67.9 (9.6)	68.1 (9.6)
	<65 years	487 (32.8)	619 (34.7)	1,106 (33.8)
	65–75 years	627 (42.2)	780 (43.7)	1,407 (43.0)
	>75 years	371 (25.0)	387 (21.7)	758 (23.2)
Airflow obstruction	Mean (SD) FEV1 in % predicted	47.3 (18.8)	48.0 (18.9)	47.7 (18.9)
	≥50% FEV1 in % of predicted	617 (42.1)	772 (43.5)	1,389 (42.9)
	<50% FEV1 in % of predicted	847 (57.9)	1,001 (56.5)	1,848 (57.1)
Dyspneaa	Low level of breathlessness	151 (37.4)	275 (50.2)	426 (44.7)
	High level of breathlessness	253 (62.6)	273 (49.8)	526 (55.3)
Comorbidity indexb	No comorbid conditions	366 (32.4)	428 (32.9)	794 (32.7)
	Comorbid conditions in one cluster	291 (25.8)	326 (25.0)	617 (25.4)
	Comorbid conditions in ≥2 clusters	471 (41.8)	548 (42.1)	1,019 (41.9)
Depressionc	No/mild depression	414 (70.9)	546 (74.0)	960 (72.6)
	Moderate/severe depression	170 (29.1)	192 (26.0)	362 (27.4)
Level of education	Primary education or below	313 (39.6)	391 (38.3)	704 (38.9)
	Secondary education	351 (44.4)	456 (44.7)	807 (44.6)
	Higher education	127 (16.1)	173 (17.0)	300 (16.6)
Self-efficacyd	Low self-efficacy	185 (31.7)	290 (33.9)	475 (33.0)
	Moderate self-efficacy	216 (37.0)	268 (31.3)	484 (33.6)
	High self-efficacy	183 (31.3)	297 (34.7)	480 (33.4)
Living status	Living with others	548 (71.2)	572 (68.1)	1,120 (69.6)
	Living alone	222 (28.8)	268 (31.9)	490 (30.4)
Body mass index	Mean (SD)	27.2 (6.5)	27.1 (6.2)	27.1 (6.3)
	<25	539 (40.1)	641 (39.4)	1,180 (39.7)
	25–29.99	429 (31.9)	568 (34.9)	997 (33.6)
	≥30	376 (28.0)	418 (25.7)	794 (26.7)
Smoking status	Current nonsmoker	1,036 (71.8)	1,225 (71.1)	2,261 (71.4)
	Current smoker	407 (28.2)	499 (28.9)	906 (28.6)
Exacerbation frequency	0 exacerbations	188 (31.1)	194 (30.8)	382 (31.0)
	1 exacerbation	134 (22.2)	122 (19.4)	256 (20.7)
	≥2 exacerbations	282 (46.7)	314 (49.8)	596 (48.3)

Notes: Values are expressed as mean (SD) or n (%).

a Based on score modified Medical Research Council dyspnea scale⁴⁷ and categorized mMRC ≥3 or mMRC ≥2 as high level of breathlessness.

b Based on clusters Cumulative Illness Rating Scale.⁴⁸

c Based on validated cutoff scores of instrument used in each specific study.

d Categories based on tertile scores computed within each specific study.

Abbreviations: FEV₁, forced expiratory volume in 1 second; SD, standard deviation.

Table 2 Description of trials on self-management in COPD patients included in the individual patient data meta-analysis

Study	Country	Sample size	Setting	Intervention group	Control group	Duration intervention (months)
Bischoff et al^Citation8 2012	the Netherlands	165	General practice	A: Two to four individual sessions by nurse, action plan, follow-up six phone calls B: Two to four routine monitoring sessions by nurse	Usual care	24
Bourbeau et al^Citation5 2003	Canada	191	Clinic/hospital	Seven individual sessions by nurse/respiratory therapist/physiotherapist, one physical exercise session, workbook, action plan, follow-up monthly telephone calls	Usual care	12
Bucknall et al^Citation7 2012	UK	464	Clinic/hospital	Four individual home visits by nurse, action plan, follow-up by home visits at least every 6 weeks	Usual care	12
Casas et al^Citation27 2006	Belgium, Spain	155	Clinic/hospital	One individual session, minimally one home visit by nurse/physician, action plan, follow-up four telephone calls	Usual care	1
Coultas et al^Citation28 2005	US	217	General practice	A: One individual session by nurse, follow-up six telephone calls B: One individual session by nurse, follow-up seven telephone calls	Usual care	6
Effing et al^Citation29 2009	the Netherlands	153	Clinic/hospital	A: Four group sessions by nurse/physiotherapist, action plan, physical training for 11 months, follow-up three telephone calls B: Four group sessions by nurse/physiotherapist, action plan, follow-up three telephone calls C: Four group sessions by nurse/physiotherapist, 11 months physical training	Usual care + four group sessions on self-management	12
Gallefoss et al^Citation30 1999	Norway	53	Clinic/hospital	Two group sessions, minimally two individual sessions by multidisciplinary team, action plan	Usual care	0.5
McGeoch et al^Citation31 2006	New Zealand	161	General practice	One individual session by nurse, action plan	Usual care	1 day
Monninkhof et al^Citation32 2003	the Netherlands	248	Clinic/hospital	Five group sessions by nurse/physiotherapist, action plan, physical training program for 2 years	Usual care	4
Nguyen et al^Citation33 2013	US	125	Combination	A: One home visit, six group sessions by nurse, educational booklet, follow-up biweekly telephone calls B: Digital learning environment, one home visit, six chat sessions with nurse, follow-up biweekly e-mails	Usual care + home visit, monthly group sessions on health education, biweekly telephone calls	12
Rice et al^Citation6 2010	US	743	Clinic/hospital	One group session by respiratory therapist, individualized action plan, follow-up monthly telephone calls	Usual care + educational handout	12
Taylor et al^Citation34 2012	UK	116	General practice	Seven group sessions by two lay peer tutors, action plan	Usual care	1.6
Trappenburg et al^Citation35 2011	the Netherlands	233	Combination	One individual session by nurse, action plan, follow-up two telephone calls	Usual care + log s	4
Zwar et al^Citation36 2012	Australia	258	General practice	Two home visits by nurse, two visits to physician, action plan, follow-up five telephone calls	Usual care	6

Abbreviation: COPD, chronic obstructive pulmonary disease.

Table 3 Effects of self-management interventions in patients with COPD

Outcome	N studies	n patients	Effect measure	Treatment effect	95% CI
Health-related quality of life
At 6 months	9	1,876	SMD	0.05	(−0.05–0.15)
At 12 months	10	2,663	SMD	0.08	(0.00–0.16)
Respiratory-related hospitalization
Time-to-first-event	6	1,872	HR	0.79	(0.66–0.94)
Within 6 months	8	2,347	RR	0.87	(0.69–1.09)
Within 12 months	9	2,426	RR	0.77	(0.64–0.93)
All-cause hospitalization
Time-to-first-event	4	1,559	HR	0.80	(0.69–0.93)
Within 6 months	6	2,034	RR	0.81	(0.67–0.97)
Within 12 months	5	1,817	RR	0.84	(0.73–0.96)
Mortality
Time-to-event	7	2,120	HR	1.02	(0.76–1.37)
Within 6 months	9	2,490	RR	1.06	(0.62–1.82)
Within 12 months	7	2,182	RR	1.04	(0.64–1.69)

Abbreviations: CI, confidence interval; HR, hazard ratio; RR, risk ratio; SMD, standardized mean difference.

Figure 1 Forest plot of effects of self-management interventions on health-related quality of life, respiratory-related and all-cause hospitalization, and mortality in patients with COPD.

Abbreviations: CI, confidence interval; HR, hazard ratio, SMD, standardized mean difference.

Table 4 Effects of self-management interventions in subgroups of patients with COPD

Outcome	n patients	Subgroup	Effect measure	Univariable analysis			Multivariable analysis
				Treatment effect	95% CI	P-value for interaction	Treatment effect	95% CI	P-value for interaction
Health-related quality of life
At 6 months		No subgroup effects
At 12 months		No subgroup effects
Respiratory-related hospitalization
Time-to-first-event	1,214	Males	HR	0.68	(0.54–0.84)	0.022	0.78	(0.55–1.09)	0.130
	497	Females		1.05	(0.78–1.42)		1.07	(0.78–1.48)
	549	No comorbidities	HR	0.93	(0.72–1.20)	0.073	0.78	(0.55–1.09)	0.206
	380	Comorbidities in one cluster		0.52	(0.33–0.80)		0.48	(0.31–0.76)
	710	Comorbidities in >1 cluster		0.72	(0.52–1.00)		0.70	(0.50–0.97)
6 months	1,544	Males	OR	0.67	(0.50–0.88)	0.005	0.61	(0.41–0.90)	0.006
	803	Females		1.36	(0.91–2.04)		1.24	(0.76–2.02)
	835	BMI <25	OR	0.77	(0.54–1.11)	0.043	0.61	(0.41–0.90)	0.038
	636	BMI 25–29.99		1.23	(0.78–1.93)		1.01	(0.63–1.61)
	618	BMI ≥30		0.55	(0.34–0.88)		0.44	(0.27–0.72)
12 months	281	Low self-efficacy	OR	0.85	(0.46–1.59)	0.036	a
	277	Moderate self-efficacy		0.39	(0.21–0.75)
	250	High self-efficacy		0.89	(0.47–1.71)
All-cause hospitalization
Time-to-first-event	539	No comorbidities	HR	0.88	(0.71–1.09)	0.056	a
	384	Comorbidities in one cluster		0.57	(0.41–0.78)
	636	Comorbidities in >1 cluster		0.89	(0.68–1.15)
6 months	698	≥50% FEV1 % predicted	RR	1.02	(0.78–1.34)	0.016	a
	1,336	<50% FEV1 % predicted		0.71	(0.58–0.88)
12 months	614	≥50% FEV1 % predicted	OR	1.03	(0.73–1.46)	0.032	1.30	(0.54–3.12)	0.232
	1,203	<50% FEV1 % predicted		0.63	(0.49–0.81)		0.82	(0.40–1.68)
	222	Low self-efficacy	OR	0.93	(0.47–1.86)	0.047	1.30	(0.54–3.12)	0.062
	239	Moderate self-efficacy		0.35	(0.18–0.71)		0.52	(0.21–1.29)
	195	High self-efficacy		0.92	(0.46–1.86)		1.31	(0.54–3.20)
Mortality
Time-to-event	549	No comorbidities	HR	1.56	(0.90–2.72)	0.075	b
	380	Comorbidities in one cluster		0.66	(0.29–1.49)
	710	Comorbidities in >1 cluster		0.77	(0.46–1.31)
	140	Less breathlessness	HR	5.33	(0.69–40.91)	0.091	b
	248	More breathlessness		0.83	(0.22–3.09)
6 months	1,707	Males	OR	0.79	(0.42–1.49)	0.071	1.40	(0.64–3.05)	0.123
	783	Females		1.83	(0.82–4.11)		2.89	(1.19–7.02)
	976	BMI <25	OR	1.83	(0.94–3.55)	0.016	1.40	(0.64–3.05)	0.026
	817	BMI 25–29.99		0.70	(0.33–1.51)		0.54	(0.23–1.26)
	697	BMI ≥30		0.46	(0.15–1.35)		0.35	(0.11–1.10)
12 months	1,557	Males	RR	0.85	(0.51–1.42)	0.092	1.18	(0.62–2.26)	0.445
	625	Females		1.59	(0.77–3.28)		1.57	(0.80–3.08)
	627	No Comorbidities	RR	1.37	(0.80–2.35)	0.074	1.18	(0.62–2.26)	0.213
	485	Comorbidities in 1 cluster		0.64	(0.31–1.30)		0.60	(0.30–1.25)
	669	Comorbidities in >1 cluster		0.71	(0.43–1.16)		0.70	(0.43–1.15)

Notes: Results of the subgroup analyses are only presented if a potential effect modifier showed an effect with P<0.10 in the univariable analysis.

a Multivariable analysis was only performed if ≥2 potential effect modifiers in the univariable analysis to adjust for other potential effect modifiers.

b Multivariable analysis not executed as this would result in N=1 study.

Abbreviations: BMI, body mass index; CI, confidence interval; COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 second; HR, hazard ratio; OR, odds ratio; RR, risk ratio.

BestallJCPaulEAGarrodRGarnhamRJonesPWWedzichaJAUsefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary diseaseThorax19995458158610377201

 PubMed Web of Science ®Google Scholar

LinnBSLinnMWGurelLCumulative illness rating scaleJ Am Geriatr Soc1968166226265646906

 PubMed Web of Science ®Google Scholar

BischoffEWAkkermansRBourbeauJComprehensive self management and routine monitoring in chronic obstructive pulmonary disease patients in general practice: randomised controlled trialBMJ2012345e764223190905

 PubMed Web of Science ®Google Scholar

BourbeauJJulienMMaltaisFReduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management interventionArch Intern Med200316358559112622605

 PubMed Web of Science ®Google Scholar

BucknallCEMillerGLloydSMGlasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trialBMJ2012344e106022395923

 PubMed Web of Science ®Google Scholar

CasasATroostersTGarcia-AymerichJIntegrated care prevents hospitalizations for exacerbations in COPD patientsEur Respir J20062812313016611656

 PubMed Web of Science ®Google Scholar

CoultasDFrederickJBarnettBSinghGWludykaPA randomized trial of two types of nurse-assisted home care for patients with COPDChest20051282017202416236850

 PubMed Web of Science ®Google Scholar

EffingTKerstjensHvan der ValkPZielhuisGvan der PalenJ(Cost)-effectiveness of self-treatment of exacerbations on the severity of exacerbations in patients with COPD: the COPE II studyThorax20096495696219736179

 PubMed Web of Science ®Google Scholar

GallefossFBakkePSKjaersgaardPKQuality of life assessment after patient education in a randomized controlled study on asthma and chronic obstructive pulmonary diseaseAm J Respir Crit Care Med199915981281710051255

 PubMed Web of Science ®Google Scholar

McGeochGRWillsmanKJDowsonCASelf-management plans in the primary care of patients with chronic obstructive pulmonary diseaseRespirology20061161161816916335

 PubMed Web of Science ®Google Scholar

MonninkhofEvan der ValkPvan der PalenJvan HerwaardenCZielhuisGEffects of a comprehensive self-management programme in patients with chronic obstructive pulmonary diseaseEur Respir J20032281582014621090

 PubMed Web of Science ®Google Scholar

NguyenHQDoneskyDReinkeLFInternet-based dyspnea self-management support for patients with chronic obstructive pulmonary diseaseJ Pain Symptom Manage201346435523073395

 PubMed Web of Science ®Google Scholar

RiceKLDewanNBloomfieldHEDisease management program for chronic obstructive pulmonary disease: a randomized controlled trialAm J Respir Crit Care Med201018289089620075385

 PubMed Web of Science ®Google Scholar

TaylorSJCSohanpalRBremnerSASelf-management support for moderate-to-severe chronic obstructive pulmonary disease: A pilot randomised controlled trialBr J Gen Pract201262e687e69523265228

 PubMed Web of Science ®Google Scholar

TrappenburgJCMonninkhofEMBourbeauJEffect of an action plan with ongoing support by a case manager on exacerbation-related outcome in patients with COPD: a multicentre randomised controlled trialThorax20116697798421785156

 PubMed Web of Science ®Google Scholar

ZwarNAHermizOCominoECare of patients with a diagnosis of chronic obstructive pulmonary disease: a cluster randomised controlled trialMed J Aust201219739439823025736

 PubMed Web of Science ®Google Scholar