Self-management behaviors to reduce exacerbation impact in COPD patients: a Delphi study

Figures & data

Figure 1 Study design of the Delphi study.

Figure 2 Conceptual model of patients’ fluctuations in symptoms during the course of COPD.

Table 1 Inclusion and exclusion criteria of self-management behaviors

Inclusion or exclusion	Criteria
Include in final list	Median score of 7–9 for at least 2 statements, including statement 1* AND an IQR ≤2 for all 3 statements AND no statement with a median score of 1–3.
Include in next Delphi round	Each statement with an IQR >2.
Exclude	• 1 (or more) statement(s) with a median of 1–3 AND an IQR ≤2 for all 3 statements.
	• 2 (or more) statements with a median of 4–6 AND an IQR ≤2 for all 3 statements.
	• Statement 1 with a median of 4–6 AND an IQR ≤2 for all 3 statements.

Notes:

* A median of 7–9 on statement 1 was required in all cases since statement 1 investigated the association between a self-management behavior and reduction of exacerbation impact and was considered to be most important. Median 1–3= not relevant/feasible; median 4–6= uncertain; median 7–9= relevant/feasible.

Abbreviation: IQR, interquartile range.

Table 2 Demographic characteristics of the Delphi panel (n=19)*

Characteristics	n (%)
Gender
Male	15 (79)
Age (years)
30–49	9 (47)
50–69	9 (47)
>70	1 (5)
Experience in respiratory care focusing on COPD (years)
0–5	1 (5)
6–15	7 (37)
16–25	3 (16)
26–35	5 (26)
>35	3 (16)
Area of focus
Patient care	1 (5)
Research	5 (26)
Both patient care and research	13 (68)
Country
the Netherlands	8 (42)
UK	2 (11)
Belgium	1 (5)
Canada	1 (5)
USA	4 (21)
Australia	3 (16)
Discipline
Pulmonology	11 (58)
Primary care	3 (16)
Nursing	1 (5)
Physiotherapy	1 (5)
Epidemiology	3 (16)

Note:

* One expert of the panel was involved in this study by providing expert opinion on the process of the Delphi study.

Table 3 Results of Delphi round 1 and 2

Phase	Self-management behaviors rated in Delphi rounds	Behavior identified from (source)	Round 1						Round 2
			Relevancea		Improvementb		Feasibilityc		Relevancea		Improvementb		Feasibilityc
			M	IQR	M	IQR	M	IQR	M	IQR	M	IQR	M	IQR
1. Stable (low risk)	Adherence to pharmacotherapy (LABA/LAMA and/or ICS)*	Literature	8	3	8	1	7	2	8	0.75	NA	NA	NA	NA
	Influenza vaccination uptake*	Literature	7	1.25	6	2.25	7	3	NA	NA	6	2	7	0.75
	Daily physical activity*	Literature	7	2.25	9	1	7	1.25	7	1.5	NA	NA	NA	NA
	Avoiding viral or bacterial stimuli*	Literature	7	2	7	2.25	6.5	2	NA	NA	7	0.75	NA	NA
	Managing exposure to air quality**	Face validity	7	2	6	1.5	5	1.25	NA	NA	NA	NA	NA	NA
	Smoking cessation*	Literature	8	2	8	2.25	7	3	NA	NA	8	0	7	1
	Managing exposure to indoor air quality**	Delphi round 1	NA	NA	NA	NA	NA	NA	6	1.75	5	1.75	5.5	1
2. Mild deterioration	Early detection of symptom deterioration*	Face validity	8	1.25	8	0.5	7.5	1	NA	NA	NA	NA	NA	NA
	Correct increase of SABA**	Literature	6	2	5.5	2.25	6	2.25	NA	NA	6	1	6	0.75
	Performing breathing exercises**	Literature	5.5	2.25	7	3	6.5	2	5	1	7	0.75	NA	NA
	Performing energy conservation techniques**	Literature	6	1.25	6	2	6	2.25	NA	NA	NA	NA	6	0.75
3. Exacerbation	Early detection of an exacerbation*	Literature	9	1	8	2	7	1	NA	NA	NA	NA	NA	NA
	Prompt treatment with corticosteroids and/or AB (self-treatment)*	Literature	8.5	1	8	1.25	7	1.25	NA	NA	NA	NA	NA	NA
	Prompt treatment with corticosteroids and/or AB (contacting HCP)*	Literature	8.5	1	8	1.5	8	2.25	NA	NA	NA	NA	8	0
	Manage stress and anxiety*	Literature	7	1	7	0.5	6	2	NA	NA	NA	NA	NA	NA
	Correct increase of SABA**	Literature	6	3.5	NA	NA	NA	NA	6	1	NA	NA	NA	NA
	Performing breathing exercises**	Literature	6.5	2	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA
	Daily physical activity*	Literature	7	3	NA	NA	NA	NA	7	1.75	NA	NA	NA	NA
	Performing energy conservation techniques**	Literature	6	2.25	NA	NA	NA	NA	6	1	NA	NA	NA	NA
4. Recovery	Completing treatment with corticosteroids and/or AB*	Face validity	7	1.25	6.5	2.25	7	1.25	NA	NA	6.5	1	NA	NA
	Manage stress and anxiety (concerning current event)*	Literature	7	1.5	7	1.25	7	2.25	NA	NA	NA	NA	7	0.75
	Adjusted exercise- and resistance training*	Literature	7	1.25	8	2	7	1.25	NA	NA	NA	NA	NA	NA
	Daily physical activity*	Literature	8	1.5	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA
	Correct use of SABA**	Literature	6.5	3	NA	NA	NA	NA	6	0.75	NA	NA	NA	NA
	Performing energy conservation techniques**	Literature	6	2	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA
	Performing breathing exercises**	Literature	6	1.25	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA
5. Stable (at risk)	Increased awareness for recurring exacerbation*	Literature	8	2	8	2	7.5	1.25	NA	NA	NA	NA	NA	NA
	Early (re)start of pulmonary rehabilitation*	Face validity	8	2	8	2.25	7	2	NA	NA	8	0	NA	NA

Notes:

* Self-management behavior included in final list after round 1 or 2 based on median scores and consensus within the expert panel.

** Self-management behavior excluded after round 1 or 2 based on median scores and consensus within the expert panel.

a Relevance – The association of this behavior and reducing exacerbation impact (statement 1).

b Improvement – The extent to whether there is room for improvement in this behavior (statement 2).

c Feasibility – The feasibility to influence this behavior (statement 3). Scores are on a 9 point Likert scale (1= strongly disagree, 9= strongly agree); bold type indicates the returning self-management behaviors in which only statement 1 was rated and therefore scores on statements 2 and 3 are not applicable.

Abbreviations: NA, not applicable; M, median; IQR, interquartile range; AB, antibiotics; HCP, health care provider; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; ICS, inhaled corticosteroids; SABA, short-acting β2-agonist.

Table 4 Final self-management behaviors per phase of the conceptual model

Phase	Statement			Relevant and feasible self-management behaviors	Categories
	1	2	3
1. Stable phase (low risk)	✓		✓	Adherence to pharmacotherapy (LABA/LAMA and/or ICS)	Adherence to pharmacotherapy
	✓	~	✓	Influenza vaccination uptake	Influenza vaccination
	✓	✓	✓	Daily physical activity	Physical activity/exercise
	✓	✓	~	Avoiding viral or bacterial stimuli	Avoiding stimuli
	✓	✓	✓	Smoking cessation	Smoking cessation
2. Mild deterioration	✓	✓	✓	Early detection of symptom deterioration	Early detection of symptom deterioration
3. Exacerbation (including onset)	✓	✓	✓	Early detection of an exacerbation	Early detection of symptom deterioration
	✓	✓	✓	Prompt treatment corticosteroids and/or AB (self-treatment)	Medical treatment of exacerbations
	✓	✓	✓	Prompt treatment corticosteroids and/or AB (contact with HCP)	Medical treatment of exacerbations
	✓	✓	~	Manage stress and anxiety	Manage stress and anxiety
	✓	NA	NA	Daily physical activity	Physical activity/exercise
4. Recovery phase	✓	~	✓	Completing treatment of antibiotics and/or corticosteroids	Medical treatment of exacerbations
	✓	✓	✓	Manage stress and anxiety (concerning current event)	Manage stress and anxiety
	✓	✓	✓	Adjusted exercise- and resistance-training	Physical activity/exercise
	✓	NA	NA	Daily physical activity	Physical activity/exercise
5. Stable phase (at risk)	✓	✓	✓	Increased awareness for recurring exacerbation	Awareness for recurrent exacerbations
	✓	✓	✓	Early (re)start of pulmonary rehabilitation	Physical activity/exercise

Notes: Bold type indicates the returning self-management behaviors in which only statement 1 was rated. ✓ = Median of 7–9 for statement. ~ = Median of 4–6 for statement. 1= Relevance – The association of this behavior and reducing exacerbation impact (statement 1). 2= Improvement – The extent to whether there is room for improvement in this behavior (statement 2). 3= Feasibility – The feasibility to influence this behavior (statement 3).

Abbreviations: AB, antibiotics; HCP, health care provider; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; ICS, inhaled corticosteroids; NA, not applicable.

Table 5 Qualitative results of Delphi round 1 and 2

Phase	Results	Self-management behavior	Citations
1. Stable (low risk)	Experts initially disagreed on the relevance of pharmacotherapy (LABA/LAMA and/or ICS). One expert stated that high level evidence is available, whereas other experts stated that ICS use is overrated in many COPD patients and that the role of pharmacotherapy is small and only relevant to a subgroup of patients. Furthermore, experts initially disagreed on the room for improvement regarding influenza vaccination uptake. Some experts considered vaccination uptake to be high, whereas others noted that room for improvement depends on region and country. Disagreement on the feasibility to influence vaccination uptake was observed since some experts believed that influenza vaccination is already heavily promoted and uptake is hard to influence. [C1] Regarding managing exposure to air quality, experts agreed on the relevance to reduce exacerbation impact, but explained doubts regarding the feasibility to influence this behavior. [C2] Finally, for smoking cessation, comments mainly focused on the feasibility to influence this behavior. Experts believe that this is feasible and that we should keep trying; however, they also stated that current smokers often show resistance regarding quitting smoking and that it is hard to influence this behavior. [C3]	Vaccination uptake	I think that vaccination uptake is harder to influence than other pharmacotherapy. People may have stronger opinions why to do/not to do it. [C1]
		Managing exposure to air quality	I have my doubts. Patients do need to get out sometimes, and if there are prolonged periods of air pollution, I am not sure how to solve this problem. [C2]
		Quitting/cutting down smoking	Smokers with COPD are a population that often have difficulty quitting and therefore will likely require more intensive interventions to influence smoking rates. [C3]
2. Mild deterioration	Several comments focused on the relevance of correctly increasing SABA in several phases. Some experts considered SABA as obsolete and one expert believed it should not be stimulated at all. Moreover, the role of SABA was questioned regarding further symptom deterioration. [C4] Regarding breathing exercises, some experts believed that these are only relevant for very few patients and were not impressed by the strength of evidence. [C5] As well as by SABA, experts believed that performing breathing exercises leads to symptom relief, but does not influence further symptom deterioration. Moreover, experts questioned whether patients are aware of these techniques. Finally, energy conservation techniques were not considered to be relevant since experts believed that this is a more general self-management strategy and not specifically aimed at preventing exacerbations. In addition, experts believed that most patients automatically perform this behavior. [C6]	Correct increase of SABA	[…] whereas the use of SABA will lead to symptom relief, it will not (directly) influence further deterioration of the exacerbation. [C4]
		Performing breathing exercises	Little is known about the individual need for breathing exercises. It is certainly not for all patients. [C5]
		Performing energy conservation techniques	Most patients will conserve energy to reduce their symptoms during early exacerbations as a natural behavior. [C6]
3. Exacerbation	Experts directly agreed on the relevance of early detection of symptom deterioration and exacerbations in round 1. Experts believed that symptom diaries or symptom scoring with action plans can be supportive. Nevertheless, the complexity of this behavior was emphasized as well as the importance of personalized advice regarding this behavior by focusing on previously experienced symptoms with exacerbations. [C6 and 7] Initially there was disagreement between experts on the relevance of daily physical activity in both the stable phase (low risk) and exacerbation phase. Some experts stated that there is proven evidence for stimulating daily physical activity and that this is important to reduce exacerbation impact. [C8] Others were uncertain about the evidence or even believed that daily physical activity might worsen a patient’s situation when experiencing an exacerbation. [C9] Furthermore, one expert pointed out that it is uncertain when physical activity should be initiated. [C10] Finally, although there was consensus on the feasibility to influence self-treatment at exacerbation onset, some experts have commented on this. Experts were confident that self-treatment is feasible although not for all COPD patients, considering health literacy, motivation, cognitive levels and relatively high age in this population. [C11]	Early detection of an exacerbation	Collaborative self-management aimed at the early detection of the exacerbation and prompt, appropriate treatment of that exacerbation is reasonable, but this is not easily achieved. [C6] I think generic non-personalized advice will fail. These are recurrent exacerbations and emphasis should be on: ‘When you feel you are beginning to get bad, like last time […]. [C7]
		Daily physical activity	In my opinion, daily PA is important to prevent the vicious circle of breathlessness and to increase fitness and health (and thereby preventing exacerbations). [C8] The exacerbation will cause reduced activity; and encouraging the patient, who is so restricted, to increase their activity might be counter-productive and perhaps even worsen the situation (especially given common comorbidities like cardiac disease). [C9] Although physical activity is likely important, there continues to be uncertainty of when to initiate physical activity and how intensive it should be. [C10]
		Self-treatment with corticosteroids and/or AB	I think that self-treatment is indicated for a select group of patients. Otherwise overtreatment is a potential risk. [C11]
4. Recovery	Relaxation techniques were considered to be important to manage stress and anxiety at exacerbation onset. However, initially disagreement was observed in the feasibility to change this behavior during exacerbation recovery. One expert thought that stress may be challenging to overcome, while another expert believed that well-designed interventions can influence stress and anxiety. [C12]	Manage stress and anxiety	With good quality interventions/support stress and anxiety can be influenced; at least partly. [C12]
5. Stable (at risk)	Early (re)start of pulmonary rehabilitation was considered to be relevant and feasible, although initially consensus on room for improvement was lacking and challenges towards feasibility to influence this behavior were reported. One expert specifically stated that there is substantial room for improvement in this behavior based on current patient performance, but this might be out of the scope of the patients own influence or health care provider’s influence. [C13]	Early (re)start of pulmonary rehabilitation	No this is health care providing politics. [C13]

Abbreviations: LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; ICS, inhaled corticosteroids; SABA, short-acting β2-agonist; C, citation from expert; PA, physical activity; AB, antibiotics.