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

Figures & data

Figure 1 Flow diagram summarizing the selection process for clinical-effectiveness studies.

Abbreviation: RCT, randomized controlled trial.

Table 1 Characteristics of included RCTs

Reference (country)	Intervention		Control	Recruitment**	Inclusion criteria	Sample size	Characteristics of included participants			Follow-up (mths)	Outcomes
	Description	Length (wks)					Mean age (SD)	Sex (% male)	Mean FEV1% predicted (SD)
Bucknall et al, 2012 (UK)^Citation23	Supported self-management ‘Living well with COPD program’ Including prescription for self-treatment at onset of exacerbation Nurse visits: 4×40 min training sessions for 2 mths then every 6 wks Based on self-regulation theory	52	Usual care	During/immediately after inpatient admission augmented with patients from pulmonary rehabilitation	FEV1/FVC <0.7 FEV1<70%	464	69.1 (9.3)	37	40.5 (13.6)	12	Mortality COPD Admissions HRQoL Anxiety and depression Self-efficacy
Casas et al, 2006^Citation24 and Garcia-Aymerich et al, 2007 (Spain)^Citation27	Integrated care Comprehensive assessment of patients at discharge; self-management education program by specialized respiratory nurse: 2 hrs before discharge, with reinforcement sessions via telephone: 1×/wk for 1 mth; further calls at 3 mths and 9 mths; individually tailored care plan; access to specialized nurse through ICT platform including a web-based call center	52	Usual care	At discharge after inpatient admission	COPD >48 hrs admission	155 and 113	71.2 (9.0)	83	41.8 (17.3)	12	Mortality Admissions Health service utilization HRQoL Dyspnea Medication adherence Inhaler technique Lung function Health behaviors Knowledge Satisfaction
Dheda et al, 2004 (UK)^Citation25	Intensive outpatient follow-up Review of inhaler technique/medications, smoking cessation advice, exercise and nutrition advice, introduction to a support group: ≥4× over 6 mths	26	Primary care follow-up	Implied at discharge	First COPD admission	33	70.2 (7.5)	NR	41.3 (16.5)	6	Admissions HRQoL Exacerbations Lung function
Egan et al, 2002 (Australia)^Citation26	Nursing-based case management Case manager assessment, self-management education and review: on admission, during hospitalization and 1 and 6 wks post-discharge	6	Usual care	During inpatient admission	COPD diagnosis	66	52.5	48	NR	3	Admissions HRQoL Anxiety and depression Satisfaction
Hermiz et al, 2002 (Australia)^Citation28	Home-based care Community nurse home visits for self-management advice: two visits at 1 and 4 wks post-discharge	4	Usual care	During inpatient admission or emergency department	COPD diagnosis 30–80 years	177	66.9	46	NR	3	Mortality Admissions Health service utilization HRQoL Health behaviors Knowledge Satisfaction
Hernandez et al, 2003 (Spain)^Citation29	Hospital-at-home Assessed by specialist team in emergency room, immediate or early discharge with specialist nurse home assessment and education including action plans and further visits (max 4) or telephone support; structured assessment by nurse including knowledge of disease and compliance with treatment	8	Usual care	Emergency department	COPD diagnosis	222	63.8 (7.7)	NR	40.9 (16.0)	2	Mortality Admissions HRQoL Lung function Knowledge Inhaler technique Satisfaction
Kwok et al, 2004 (Hong Kong)^Citation30	Community nursing program Trained community nurse visit patients to provide health counseling (drug and nutrition advice, inhaler technique): before discharge; home visit to review patient, health counseling (including drug and diet regime, home modifications, encourage physical exercise), psychosocial support: weekly home visits for 4 wks then monthly for 6 mths	26	Usual care	During inpatient admission	Chronic lung disease 60+ years > 1 admission in previous 6 mths	157	74.7 (6.4)	71	NR	6	Mortality Admissions ED visits Exercise capacity
Lee et al, 2002 (Hong Kong)^Citation20*	Care protocol For community nurses who followed up patients for 6 mths. Included education of nursing staff and patients; 1× week for 1 mth then monthly visits and telephone advice	26	Usual care	During inpatient admission	COPD aged 65+ years Resident of nursing home > 1 admission in previous 6 mths	112 (45 homes)	80.4 (6.3)	53	NR	6	Admissions ED visits Lung function Satisfaction
Wong et al, 2005 (People’s Republic of China)^Citation31	Nurse-initiated telephone follow-up Goal setting and patient education to increase self-efficacy; management of dyspnea: two telephone calls (wks 1 and 3). Based on Bandura’s theory	3	Usual care	At discharge	COPD diagnosis Home living	60	73.6 (7.8)	78	NR	3	Admissions ED visits Self-efficacy

Notes:

* Cluster RCT;

** all admitted for an acute exacerbation.

Abbreviations: RCTs, randomized controlled trials; wk, week; COPD, chronic obstructive pulmonary disease; mth, month; min, minutes; hr, hour; max, maximum; FEV₁, forced expiratory volume in one second; SD, standard deviation; NR, not reported; HRQoL, health-related quality of life; ED, emergency department; FVC, forced vital capacity; ICT, information and communication technology.

Figure 2 Summary diagram of interventions.

Abbreviations: COPD, chronic obstructive pulmonary disease; mth, month.

Figure 3 Effect of self-management support interventions on mortality.

Abbreviations: CI, confidence interval; NR, not reported; HR, hazard ratio; int, intervention; cont, control.

Figure 4 Effect of self-management support interventions on time to first re-admission.

Notes: *COPD-related admission. All others unknown/unclear cause.
Abbreviations: COPD, chronic obstructive pulmonary disease; NR, not reported; HR, hazard ratio; CI, confidence interval; int, intervention; cont, control.

Table 2 Results of additional clinical outcomes

Reference	Brief intervention (N)	Brief control (N)	Outcome	Follow-up (mths)	Baseline intervention	Baseline control	Results intervention	Results control	Effect size (OR or mean difference, 95% CI)/P-value
GP consultations
Hermiz et al, 2002^Citation28	Home-based care focused on self-management (N=84)	Usual care (N=93)	GP reported visits to GP, mean	3	NR	NR	5.21 (N=57)	5.11 (N=64)	P=0.9
Casas et al, 2006^Citation24	Integrated care with self-management intervention (N=65)	Usual care (N=90)	Self-reported physician visits per year, median (IQR)	12	NR	NR	Barcelona: 2 (0–4) Leuven: 10 (7–18) (N=65)	Barcelona: 2 (1–4) Leuven: 13 (9–27) (N=90)	P=0.437 P=0.454
Anxiety
Lee et al, 2002^Citation20	Care protocol to nursing home (N=48 completers)	Usual care (N=41 completers)	GHQ: Anxiety and insomnia subscale, mean (SD)	6	4.31 (2.60)	3.54 (2.83)	2.8 (1.52) (N=48)	4.3 (2.49) (N=41)	−1.50 (−2.38, −0.62)*,†
Bucknall et al, 2012^Citation23	Supported self-management (N=232)	Usual care (N=232)	Hospital anxiety and depression score, mean (SD)	12	10.00 (4.5)	9.3 (4.6)	Mean change (SD) −0.37 (3.77) (N=104)	Mean change (SD) 0.93 (3.29) (N=82)	−1.06 (−2.08, −0.03)
Depression
Lee et al, 2002^Citation20	Care protocol to nursing home (N=48 completers)	Usual care (N=41 completers)	GHQ Depression subscale, mean (SD)	6	4.83 (2.40)	4.68 (3.31)	3.3 (1.86) (N=48)	4.3 (2.66) (N=41)	−1.00 (−1.97, −0.03)*,†
Bucknall et al, 2012^Citation23	Supported self-management (N=232)	Usual care (N=232)	Hospital anxiety and depression score, mean (SD)	12	8.5 (3.9)	8.3 (4.1)	0.54 (3.26) (N=109)	0.75 (2.78) (N=84)	−0.27 (−1.13, 0.59)
Exercise capacity
Kwok et al, 2004^Citation30	Community nurse supported discharge program (N=77)	Usual care (N=80)	6 minute walking distance, mean (SD)	6	162 (79) (N=71)	145 (71) (N=75)	174 (98) (N=67)	150 (89) (N=73)	24.00 (−7.10, 55.10)*
Dyspnea
Garcia-Aymerich et al, 2007^Citation27	Integrated care (N=44)	Usual care (N=69)	MRC dyspnea score, mean change (SD)	12	NR	NR	−0.52 (1.12) (N=21)	−0.15 (1.44) (N=41)	−0.38 (−1.1, 0.34)
Lung function
Garcia-Aymerich et al, 2007^Citation27	Integrated care (N=44)	Usual care (N=69)	FEV1 (l)	12	Median (IQR) 1.2 (0.8, 1.4)	Median (IQR) 1.0 (0.8, 1.5)	Mean change (SD) −0.01 (0.14) (N=21)	Mean change (SD) 0.06 (0.35) (N=41)	−0.07 (−0.19, 0.05)*
Lee 2002^Citation20, mean (SD)	Care protocol to nursing home (N=48 completers)	Usual care (N=41 (N=48) completers)	% predicted FEV1 (N=41)	6	30.6 (10.1)	34.0 (15.1)	31.1 (13.3) (N=48)	30.6 (13.1) (N=41)	0.50 (−5.00, 6.00)*,†
Hernandez et al, 2003^Citation29	Home based hospitalization (N=121)	Usual care (N=101)	FEV1 (l), mean (SD)	2	NR	NR	2.4 (0.9) (N=121)	2.2 (0.9) (N=101)	0.20 (−0.04, 0.44)*

Notes:

* Effect sizes not reported, therefore were calculated from available data in the paper;

† result not adjusted for clustering.

Abbreviations: GP, general practitioner; IQR, interquartile range; SD, standard deviation; GHQ, General Health Questionnaire; MRC, Medical Research Council; FEV₁, forced expiratory volume in one second; mth, month; OR, odds ratio; CI, confidence interval; NR, not reported.

Figure 5 Effect of self-management support interventions on health-related quality of life (SGRQ score).

Note: Positive effect signifies improvement.
Abbreviations: SGRQ, St George’s Respiratory Questionnaire; NR, not reported; ANCOVA, analysis of covariance; int, intervention; cont, control; CI, confidence interval.

Table 3 Results of patient-reported knowledge, self-efficacy, and behavior

Reference	Brief intervention (N)	Brief control (N)	Outcome	Follow-up (mths)	Baseline intervention	Baseline control	Results intervention	Results control	Effect size (OR or mean difference, 95% CI)/P-value
Self-efficacy
Wong et al, 2005^Citation31	Self-management telephone f/u (N=30)	Routine care (N=30)	Modified Chinese self efficacy scale (total) Median (IQR)	3	3.8 (0.6) (N=30)	3.6 (0.8) (N=30)	4.0 (0.6) (N=30)	3.8(1.0)(N=30)	P=0.009
Bucknall et al, 2012^Citation23	Supported self-management (N=232)	Usual care (N=232)	COPD Self efficacy score	12	Mean (SD) 68.2 (27.5)	Mean (SD) 69.8 (25.5)	Mean change (SD) −1.73 (34.04) (n=119)	Mean change (SD) −5.55 (33.72) (n=94)	2.65 (−5.85, 11.14)
Health behaviors
Hermiz et al, 2002^Citation28	Home-based care focused on self-management (N=84)	Usual care (N=93)	Behavior change/knowledge* (N [%])	3	NR	NR	Smoking: 15/67(22%) Influenza vaccination: 48/67 (72%) Pneumococcal vaccination: 42/67 (63%) Name of COPD: 36 (54%) Role of vaccination: 41 (61) Factors that prevent worsening of condition: 26 (39) When to seek help: 57 (85)	Smoking: 26/80 (33%) Influenza vaccination: 60/80 (75%) Pneumococcal vaccination: 42/80 (53%) Name of COPD: 26 (33%) Role of vaccination: 16 (20%) Factors that prevent worsening of condition: 10(13%) When to seek help: 55 (69%)	P=0.17 P=0.65 P=0.28 P=0.04 P<0.01 P<0.01 P=0.07
Hernandez et al, 2002^Citation29	Home-based hospitalization (N=121)	Usual care (N=101)	Disease Knowledge* Compliance with inhalation technique Rehabilitation at home		NR	NR	Disease knowledge: 58% Inhaler technique: 81 % Rehabilitation at home: 51%	Disease knowledge: 27% Inhaler technique: 48% Rehabilitation at home: 21%	P<0.01 P<0.001 P<0.01
Garcia-Aymerich et al, 2007^Citation27	Integrated care (N=44)	Usual care (N=69)	Life-style factors,* self-management, medical treatment Disease knowledge* (N [%])	12	NR	NR	N=21 Current smokers: 5 (24) Physical activity: 18 (86) Regular walking/exercise: 18(86) Knowledge about name of disease: 17(81) Identification of exacerbation: 17 (85) Early treatment of an exacerbation: 19 (90) Adherence to oral treatment (MAS scale): 19(90) Adherence to inhaled treatment (IAS scale): 15(71) Correct inhaler maneuver: 18 (86) Influenza vaccination: 19 (90) Pneumococcal vaccination: 16 (76)	N=41 Current smokers: 6(15) Physical activity: 34 (83) Regular walking/exercise: 32 (78) Knowledge about name of disease: 18 (44) Identification of exacerbation: 9 (22) Early treatment of an exacerbation: 27 (66) Adherence to oral treatment (MAS scale): 35 (85) Adherence to inhaled treatment (IAS scale): 15 (37) Correct inhaler maneuver: 9 (24) Influenza vaccination: 32 (78) Pneumococcal vaccination: 25 (61)	P=0.349 P=0.778 P=0.470 P=0.005 P<0.001 P=0.036 P=0.570 P=0.009 P<0.001 P=0.442 P=0.348

Note:

* No standard scores used.

Abbreviations: f/u, follow-up; IQR, interquartile range; COPD, chronic obstructive pulmonary disease; mth, month; SD, standard deviation; MAS, medication adherence scale; IAS, inhaler adherence scale; OR, odds ratio; CI, confidence interval; NR, not reported.

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