Features of self-management interventions for people with COPD associated with improved health-related quality of life and reduced emergency department visits: a systematic review and meta-analysis

Figures & data

Figure 1 PRISMA diagram of trials eligible for review data extraction.

Abbreviations: HRQOL, health-related quality of life; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT, randomized controlled trial.

Table 1 Definitions of “self-management” used across reviews

Review	Self-management definition
Jonkman et al^Citation11	Interventions providing information … and including minimally two of the following components: 1) stimulation of sign/symptom monitoring; 2) education in problem-solving skills, ie, self-treatment of acute exacerbations and stress/symptom management; 3) smoking cessation … 4) medical treatment adherence; 5) physical activity; or 6) improving dietary intake.
Jonkman et al^Citation10	In addition to education about the condition … two of the following components … : 1) stimulation of sign/symptom monitoring, 2) education in problem-solving skills (ie, managing acute exacerbations/symptoms, resource utilisation), … 3) medication adherence, 4) physical activity, 5) dietary intake, and/or 6) smoking cessation.
Zwerink et al^Citation7	Interventions required an iterative interaction process between participant and health care provider, preferably goal formulation and feedback and two of the following: smoking cessation, self-recognition/self-treatment of exacerbations, exercise/physical activity component, dietary advice, medication advice, or coping with breathlessness. Participant education only intervention were excluded.
Adams et al^Citation29	Education (giving information alone) and/or behavioral support (providing tools to modify behaviors) and/or motivational (linking specific goals for behavioral changes to clinical information)
Bourbeau^Citation32	Education program included training that integrated specific skills for patients to control their disease and live functional lives. Program could also include education about acute exacerbation recognition and action to be taken, as well as periodic home visits/telephone calls provided by a health professional
Blackstock and Webster^Citation31	Education focusing on changing health behaviors through knowledge, goal setting, and development of action plans. Needed at least one occasion where the participant(s) had face-to-face interaction with the health professional. Education not delivered in a formal manner was considered usual care
Harrison et al^Citation33	Action plan involving symptom monitoring and medical management as well as education providing knowledge and information on decision-making. Must include two of following: self-efficacy, problem solving, resource utilization, collaboration, emotional management, role management, and goal setting. Excluded action plans alone and supervised exercise training.
Monninkhof et al^Citation35	Could involve COPD education and/or self-treatment (action plan) guidelines. Education included written material or structured verbal interaction with a health care provider, but as part of a programme to improve COPD knowledge and understanding. Self-treatment guidelines (action plan) were written plans for self-management of exacerbations.
Walters et al^Citation36	Use of guidelines detailing self-initiated interventions (ie, changing medication regime, visiting GP/hospital), which were undertaken in response to alterations in the patients’ COPD (eg, increase in breathlessness, sputum). Educational component permitted if duration was up to 1 hour. Excluded broader self-management support interventions.
Majothi et al^Citation34	Included one or more components commonly included in self-management interventions, such as action plans, exercise, education, inhaler technique, bronchial hygiene and breathing techniques, stress management and relaxation, nutritional programs, patient empowerment, support groups, and telecare
Bentsen et al^Citation30	Self-management is defined as the individual’s ability to manage his/her symptoms, treatment, physical and psychosocial consequences, and lifestyle changes when living with a chronic condition

Table 2 Overlap of individual studies across reviews

Individual studies	Reviews											Total
	Jonkman et al^Citation11	Jonkman et al^Citation10	Zwerink et al^Citation7	Adams et al^Citation29	Bourbeau^Citation32	Blackstock and Webster^Citation31	Harrison et al^Citation33	Monninkhof et al^Citation35	Walters et al^Citation36	Majothi et al^Citation34	Bentsen et al^Citation30
Bourbeau et al 2003^Citation37	X	X	X	X	X	X					X	7
Watson et al 1997^Citation38	X	X		X	X	X		X	X			7
Gallefoss et al 1999^Citation39	X		X	X	X	X		X				6
Emery et al 1998^Citation40			X	X	X	X		X				5
Garcia-Aymerich et al 2007^Citation41	X	X	X				X			X		5
Monnonkhof et al 2004^Citation42	X	X	X	X							X	5
Bucknall 2012^Citation43	X	X					X			X		4
Littlejohns 1991^Citation44				X	X	X		X				4
Wood-Baker et al 2006^Citation45	X	X					X		X			4
Coultas et al 2005^Citation46	X	X	X									3
Hermiz et al 2002^Citation47				X			X			X		3
Khdour et al 2009^Citation48	X	X	X									3
McGeoch et al 2006^Citation49	X	X							X			3
Ninot et al 2011^Citation50	X		X								X	3
Rice et al 2010^Citation51	X	X	X									3
Wakabayashi et al 2011^Citation52	X	X	X									3
Bischoff et al 2012^Citation53	X	X										2
Fan et al^Citation54	X	X										2
Koff et al 2009^Citation55		X	X									2
Taylor et al 2012^Citation56	X	X										2
Trappenburg et al 2011^Citation57	X	X										2
Zwar et al 2012^Citation58	X	X										2
Faulkner 2010^Citation59			X									1
Kheirabadi 2008^Citation60			X									1
Moullec 2008^Citation61			X									1
Rootmensen 2008^Citation62									X			1
Total	18	17	14	7	5	5	4	4	4	3	3

Table 3 BCTs used across studies eligible in meta-analysis

Abbreviations: BCT, behavior change technique; SMD, standardized mean differences; MM, nurse-assisted medical management; CM, nurse-assisted collaborative management.

Table 4 Intervention features and number of BCTs targeting different behaviors across SMIs

Intervention studies grouped by effect size	SMD	P-value	Number of BCTs targeted for each behavior				Intervention features (1 = Yes)
			Total	Symptom	Mental health	Physical activity	Group component	Multiple session	Single providera
Medium effect size (SMD ≥0.5)
Moullec 2008^Citation61	−2.44	<0.001	8	2	2	4	1	1	–
Emery et al 1998^Citation40; exercise	−0.74	0.03	9	2	4	3	1	1	–
Koff et al 2009^Citation55	−0.71	0.03	8	7	1	–	–	1	1
Small effect size (0.5> SMD ≥0.2)
Kheirabadi 2008^Citation60	−0.42	0.17	9	6	2	1	1	1	NR
Bucknall et al 2012^Citation43	−0.36	0.05	15	12	3	–	–	1	1
Bourbeau et al 2003^Citation37	−0.35	0.02	15	7	2	6	–	1	1
Wakabayashi et al 2011^Citation52	−0.26	0.21	4	3	–	1	–	1	–
Ninot et al 2011^Citation50	−0.24	0.46	9	4	–	5	1	1	1
Rice et al 2010^Citation51	−0.23	0.02	13	8	4	1	NR	1	1
Khdour et al 2009^Citation48	−0.20	0.21	11	9	–	2	–	1	1
Limited effect (SMD <0.2)
Coultas 2005^Citation46; MM	−0.19	0.43	3	3	–	–	–	1	1
Coultas 2005^Citation46 CM	−0.18	0.45	3	3	–	–	–	1	1
Gallefoss et al 1999^Citation39	−0.17	0.55	8	8	–	–	1	1	–
Garcia-Aymerich et al 2007^Citation41	−0.16	0.55	6	5	–	1	–	1	–
Trappenburg et al 2011^Citation57	−0.14	0.35	8	7	–	1	–	1	1
Littlejohns et al 1991^Citation44	−0.13	0.45	4	4	–	–	–	1	1
Rootmensen 2008^Citation62	−0.12	0.45	6	6	–	–	–	–	1
Hermiz et al 2002^Citation47	−0.10	0.54	5	4	–	1	–	–	1
McGeoch et al 2006^Citation49	−0.09	0.58	7	5	–	2	–	–	1
Fan et al 2012^Citation54	−0.04	0.79	6	4	1	1	1	1	1
Bischoff et al 2012^Citation53	−0.03	0.88	8	6	1	1	–	1	1
Faulkner 2010^Citation59	−0.02	0.96	10	2	–	8	1	1	1
Monninkhof et al 2004^Citation42	−0.02	0.90	12	5	–	7	1	1	–
Taylor et al 2012^Citation56	−0.02	0.94	18	10	6	2	1	1	1
Watson et al 1997^Citation38	0.00	1.00	8	6	–	2	–	–	–
Emery et al 1998^Citation40; no exercise	0.04	0.91	6	2	4	–	1	1	–
Zwar et al 2012^Citation58	0.06	0.54	5	4	–	1	–	1	–
Wood-Baker et al 2006^Citation45	0.21	0.25	3	3	–	–	–	–	–

Notes:

a Intervention delivered by a single provider (of any profession) rather than multidisciplinary team. Bold values are statistically significant.

Abbreviations: BCT, behavior change technique; SMD, standardized mean difference; SMI, self-management intervention; MM, nurse-assisted medical management; CM, nurse-assisted collaborative management; NR, not reported.

Table 5 SMD, 95% CIs for the effect of self-management interventions compared with control conditions on measures of health-related quality of life, with measures of heterogeneity

Moderators	Number of interventions	Number of participants within trials			Measure of effect
		Total	Intervention	Control	SMD (95% CI)	P-value
Overall effect	28	3,518	1,827	1,691	−0.16 (−0.25 to −0.07)	0.001
Severitya
Moderate	10	1,172	610	562	−0.12 (−0.28 to 0.03)	0.12
Severe	14	1,644	874	770	−0.21 (−0.35 to −0.08)	0.01
Between group						0.39
Model of careb
Single practitioner	17	2,297	1,204	1,093	−0.17 (−0.29 to −0.06)	<0.01
Multidisciplinary team	9	1,117	581	536	−0.10 (−0.27 to 0.07)	0.23
Between group						0.49
Duration of intervention
Single session	5	637	321	316	−0.03 (−0.23 to 0.17)	0.77
Multiple session	23	2,881	1,506	1,375	−0.19 (−0.29 to −0.09)	<0.001
Between group						0.17
Session format
Individual	17	2,301	1,182	1,119	−0.14 (−0.25 to −0.02)	0.02
Group	10	789	420	369	−0.20 (−0.39 to 0.01)	0.04
Between group						0.56
Mental health
Targeted	11	1,313	698	615	−0.27 (−0.41 to −0.13)	<0.001
Not targeted	17	2,205	1,129	1,076	−0.08 (−0.19 to 0.02)	0.12
Between group						0.04
Physical activity
Targeted	18	2,550	1,297	1,253	−0.17 (−0.28 to −0.05)	<0.01
Not targeted	10	968	530	438	−0.14 (−0.30 to −0.02)	0.08
Between group						0.83

Notes: The number of participants has now been added as additional columns. The number of trials will not always equal 28 as missing data in some studies.

a Sample were, at baseline, predominantly classified as severe according to GOLD criteria. Studies may not have actively recruited a severe sample.

b Intervention was delivered by a single provider (of any profession) rather than multidisciplinary team. Bold values indicate significant values.

Abbreviations: CI, confidence interval; GOLD, Global Initiative for Chronic Obstructive Lung Disease; SMD, standardized mean difference.

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