Self-management of health care behaviors for COPD: a systematic review and meta-analysis

Figures & data

Figure 1 Flow diagram summarizing the study selection process.

Abbreviaiton: RCT, randomized controlled trial.

Table 1 Characteristics of the trials and their populations

Characteristic	n	(%)
Setting
North America	41	23.7
Europe	82	47.4
Australasia	18	10.4
Asia	22	12.7
Other	10	5.8
Sample size
<50	81	46.8
50–99	46	27.2
100+	46	26.2
Age (mean/years)
50–59	11	6.3
60–69	111	63.8
70–79	29	16.7
80+	1	0.6
Not reported as mean age	21	12.1
Males (n, %)
1%–25%	4	2.3
26%–50%	36	20.8
51%–75%	62	35.8
75%–100%	51	29.5
Not reported	20	11.6
FEV1 % predicted (mean)
50–79	44	25.4
30–49	90	50.0
<30	5	2.9
Not reported as mean FEV1 % predicted	34	19.6
Recruited from:
Secondary care in-patient	15	8.7
Secondary care outpatient/unspecified	82	47.4
Emergency department	1	0.6
Pulmonary rehabilitation program/referral	21	12.1
Primary care	9	5.2
Primary and secondary care	3	1.7
Community	3	1.7
Primary or secondary care and advertisement	18	10.4
Not reported/unclear	21	12.1
Duration of intervention (weeks)
≤13	118	65.3
14–26	28	16.2
27+	26	15.0
Unclear	6	3.5
Mode of intervention delivery
Group	62	35.8
Individual	63	36.4
Mixed group and one-to-one	24	13.9
Remote	4	2.3
Unclear	20	11.6
Time to last follow-up (weeks)
≤13	78	45.0
14–26	42	24.3
27–52	43	24.8
>52	8	4.6
Unclear	2	1.2
Time from end of intervention to last follow-up (weeks)
0	106	61.3
≤13	27	15.6
14–26	16	9.2
27–52	16	8.7
>52	3	1.7
Unclear	6	3.5

Note: n refers to number of studies.

Table 2 Summary of risk of bias

Risk of bias	Low	High	Unclear	Total
	n %	n %	n %
Sequence generation	66	0	107	173
	38.2	0	62.8
Allocation concealment	27	1	145	173
	15.6	0.6	83.8
Blinding of HRQoL outcome	33	117	23	173
	19.1	67.6	13.3
Blinding of admission outcome	44	0	1	45
	97.8	0	2.2
Incomplete outcome data	46	82	45	173
	26.6	50.0	26.0
Selective outcome reporting	54	2	117	173
	31.2	1.2	67.6
Other biases	44	86	43	173
	25.4	49.7	24.9

Notes: n refers to number of studies. Other biases include: only presenting the baseline characteristics of participants who completed follow-up; baseline differences between study groups; limited baseline characteristics reported.

Abbreviation: HRQoL, health-related quality of life.

Table 3 Effect of single components on HRQoL and hospital admissions

Intervention and timing of study follow-up	HRQoL				Hospital admissions
	Number of studies (comparisons)	Number of participants	Summary MDa (95% CIs)	I^2 (%)	Number of studies (comparisons)	Number of participants	Summary HR (95% CIs)	I^2 (%)
Exercise only					1 (2)	207	1.12 (0.29–4.36)	0.0
SGRQ at <3 m	4 (5)	320	4.87 (3.96–5.79)*	0.0
SGRQ at >6 m	1	19	8.50 (−2.29 to 19.29)	n/a
CRQ at <3 m	2	106	0.70 (−0.07 to 1.47)	68.6
CRQ at >3 to ≤6 m	2	146	1.17 (−0.35 to 2.69)	92.5
Exercise in addition
SGRQ at 3–12 m	2	75	8.20 (−2.28 to 18.67)	41.1	–	–	–	–
CRQ at 3–12 m	3	156	0.71 (−0.30 to 1.73)	82.4
Action plans					1 (12 m)	154	0.97 (0.33–2.89)	n/a
SGRQ at 6–12 m	4	587	0.43 (−1.69 to 2.54)	0.0	1 (6 m)	216	1.12 (0.77–1.62)	n/a
Breathing techniques
SGRQ at <3 m	2	78	5.00 (4.06–5.94)*	0.0	–	–	–	–
CRQ at <3 m	1	43	0.17 (0.09–0.43)	n/a
DAS
SGRQ at <3 m	1	24	−1.20 (−12.01 to 9.61)	n/a	–	–	–	–
Food fortification
SGRQ at 12 m	1	66	10.10 (1.70–18.50)*	n/a	–	–	–	–
Patient support groups
SGRQ at 12 m	1	85	1.40 (−4.14 to 6.94)	n/a	–	–	–	–

Notes:

* P<0.05.

a Positive MD represents an improvement for SGRQ and CRQ. – indicates no data.

Abbreviations: CIs, confidence intervals; CRQ, chronic respiratory disease questionnaire; DAS, distraction auditory therapy during exercise; HRQoL, health-related quality of life; HR, hazard ratio; MD, mean difference; n/a, not applicable; SGRQ, St George’s respiratory questionnaire; m, months.

Table 4 Effect of different multicomponent self-management intervention compared to usual care on hospital admissions

Intervention	Follow-up at ≤3 months			Follow-up at >3 to ≤6 months			Follow-up at >6 months
	Number of studies (participants)	Summary HR (95% CIs)	I^2 (%)	Number of studies (participants)	Summary HR (95% CIs)	I^2 (%)	Number of studies	Summary HR (95% CIs)	I^2 (%)
Multicomponent	8 (879)	0.94 (0.73–1.20)	0.0	4 (353)	0.56 (0.22–1.42)	77.8	8 (1,810)	0.79 (0.60–1.05)	62.6
Multicomponent with supervised exercise	4 (321)	0.78 (0.54–1.14)	0.0	1 (46)	0.55 (0.25–1.18)	n/a	2 (86)	0.47 (0.08–2.60)	83.8
Multicomponent with structured, unsupervised exercise	–	–	–	–	–	–	1 (191)	0.55 (0.35–0.87)*	n/a
Multicomponent with exercise counseling only	2 (296)	1.40 (0.93–2.11)	0.0	3 (307)	0.52 (0.13–2.09)	81.0	3 (994)	0.79 (0.50–1.26)	67.9
Multicomponent without exercise advice or support	1 (40)	0.32 (0.03–3.03)	n/a	–	–	–	2 (539)	0.99 (0.76–1.30)	0.0

Notes: – indicates no data.

* P<0.05.

Abbreviations: CIs, confidence interval; HR, hazard ratio; n/a, not applicable.

Table 5 Effect of different multicomponent self-management intervention compared to usual care on HRQoL

Intervention	Follow-up at ≤3 months			Follow-up at >3 to ≤6 months			Follow-up at >6 months
	Number of studies (participants)	Summary MD (95% CIs)	I^2 (%)	Number of studies (participants)	Summary MD (95% CIs)	I^2 (%)	Number of studies (participants)	Summary MD (95% CIs)	I^2 (%)
Multicomponent
SGRQ	18 (1,296)	6.50 (3.62–9.39)*	82.4	14a (1,905)	4.47 (1.93–7.02)*	79.6	16 (2,816)	2.40 (0.75–4.04)*	57.9
CRQ	7 (430)	0.40 (0.01–0.79)*	75.7	5 (360)	1.02 (0.05–1.98)*	93.2	3 (272)	1.21 (−0.47 to 2.88)	96.2
Multicomponent with supervised exercise
SGRQ	14 (841)	7.75 (3.49–12.01)*	80.1	6 (580)	6.57 (3.24–9.90)*	77.6	4 (251)	1.13 (−2.81 to 5.08)	0.0
CRQ	7 (416)	0.43 (0.03–0.83)*	77.8	6 (380)	1.02 (0.19–1.86)*	92.0	3 (272)	1.21 (−0.47 to 2.88)	95.2
Multicomponent with structured, unsupervised exercise
SGRQ	–	–	–	–	3.59 (1.28 to 5.91)*	0.0	5 (776)	0.80 (−1.03 to 2.63)	2.3
CRQ	1 (34)	0.61 (−0.18 to 1.41)	n/a	4 (714)	–	–	–	–	–
Multicomponent with exercise counseling only
SGRQ	1 (177)	1.32 (−2.97 to 5.61)	n/a	3 (305)	1.87 (−4.43 to 8.18)	71.2	4 (1,021)	3.88 (−1.39 to 9.14)	74.6
CRQ	–	–	–	–	–	–	–	–	–
Multicomponent without exercise advice or support
SGRQ	3 (278)	4.65 (−1.45 to 10.74)	82.0	2 (218)	2.75 (−3.24 to 8.74)	0.0	3 (702)	3.73 (−0.99 to 8.44)	81.1
CRQ	–	–	–	–	–	–	–	–	–

Notes: Positive MD represents an improvement for SGRQ and CRQ.

* P<0.05.

a 15 comparisons. – indicates no data.

Abbreviations: CIs, confidence interval; CRQ, chronic respiratory disease questionnaire; HRQoL, health-related quality of life; MD, mean difference; SGRQ, St George’s respiratory questionnaire; n/a, not applicable.

Figure 2 HRQoL (SGRQ) outcomes for multicomponent self-management intervention versus usual care.

Notes: ^Indicates that several papers are represented by this lead publication. A = nurse-assisted collaborative management vs UC. B = nurse-assisted medical management vs UC.
Abbreviations: ANCOVA, analysis of covariance; CI, confidence interval; HRQoL, health-related quality of life; Int, intervention group; Cont, control group; SGRQ, St George’s respiratory questionnaire; UC, usual care.

Figure S1 HRQoL (SGRQ) at final follow-up for comparisons assessing the effects of one additional component of self-management.

Abbreviations: ANCOVA, analysis of covariance; CI, confidence interval; HRQoL, health-related quality of life; SGRQ, St George’s respiratory questionnaire; Int, intervention group; Cont, control group.

Figure S2 HRQoL (CRQ) at final follow-up for comparisons assessing the effects of one additional component of self-management.

Note: D = rehabilitation (traditional and modern) + qigong + breathing training + limb training vs modern rehabilitation + breathing training + limb training.

Abbreviations: ANCOVA, analysis of covariance; CI, confidence interval; HRQoL, health-related quality of life; CRQ, Chronic Respiratory disease Questionnaire.

Figure S3 HRQoL (SGRQ) outcomes for exercise-only interventions versus usual care/sham intervention.

Note: *The control group that has been halved in size (split between two comparisons). A = t’ai chi qigong vs control. B = exercise vs control.

Abbreviations: ANCOVA, analysis of covariance; CI, confidence interval; HRQoL, health-related quality of life; SGRQ, St George’s respiratory questionnaire.

Figure S4 Hospital admissions for multicomponent self-management interventions versus usual care.

Notes: B = exercise vs control. ^Several papers are represented by this lead publication.

Abbreviations: ANCOVA, analysis of covariance; CI, confidence interval; HR, hazard ratio.

Figure S5 HRQoL (CRQ) outcomes for multicomponent self-management intervention versus usual care.

Note: A = rehabilitation (traditional and modern) + qigong + breathing training + limb training vs UC.

Abbreviations: ANCOVA, analysis of covariance; CI, confidence interval; HRQoL, health-related quality of life; CRQ, Chronic Respiratory disease Questionnaire; UC, usual care.

Figure S6 HRQoL (SGRQ) outcomes for multicomponent self-management interventions including supervised exercise versus usual care/control.

Notes: B = exercise vs control. ^Several papers are represented by this lead publication.

Abbreviations: ANCOVA, analysis of covariance; CI, confidence interval; HRQoL, health-related quality of life; SGRQ, St George’s respiratory questionnaire.

Figure S7 HRQoL (CRQ) outcomes for multicomponent self-management interventions including supervised exercise versus usual care/control.

Note: A = rehabilitation (traditional and modern) + qigong + breathing training + limb training vs UC.

Abbreviations: ANCOVA, analysis of covariance; CI, confidence interval; HRQoL, health-related quality of life; CRQ, Chronic Respiratory disease Questionnaire; UC, usual care.

Figure S8 HRQoL (SGRQ) outcomes for multicomponent self-management interventions with structured, unsupervised exercise versus usual care/control.

Abbreviations: ANCOVA, analysis of covariance; CI, confidence interval; HRQoL, health-related quality of life; SGRQ, St George’s respiratory questionnaire.

Figure S9 HRQoL (SGRQ) outcomes for multicomponent self-management interventions with exercise counseling only versus usual care/control.

Note: ^Several papers are represented by this lead publication.

Abbreviations: ANCOVA, analysis of covariance; CI, confidence interval; HRQoL, health-related quality of life; SGRQ, St George’s respiratory questionnaire.

Figure S10 HRQoL (SGRQ) outcomes for multicomponent self-management interventions without an exercise element versus usual care/control.

Notes: *The control group that has been halved in size (split between two comparisons). A = nurse-assisted collaborative management vs UC; B = nurse-assisted medical management vs UC.

Abbreviations: ANCOVA, analysis of covariance; CI, confidence interval; HRQoL, health-related quality of life; SGRQ, St George’s respiratory questionnaire; UC, usual care.

Table S1 Definitions of components of self-management

Component	Broad inclusion/definition
Disease knowledge	Education about disease, disease management, treatments, self-management, chronic illness, activities of daily life, end of life, self-care tips, travel, and COPD
Self-management unspecified	Self-management education/skills
Respiratory muscle training	Inspiratory muscle training, expiratory muscle training (pressure, threshold, and resistance devices)
Action planning	Managing exacerbations, coping plan, management of COPD symptoms, recognizing when to call a doctor
Breathing management and techniques	Breathing exercises, breathing retraining, respiratory biofeedback, managing breathlessness and coping with triggers for breathlessness, tai chi, vocal exercises
Smoking cessation	Advice, counseling, groups, interventions to help reduce/quite smoking as required
Medication/adherence	Information about medication and adherence, promoting adherence (pharmacological or nonpharmacological)
Bronchial hygiene techniques	Postural drainage/coughing technique
Nutrition	Advice, counseling, groups, supplements as required
Psychological intervention	Psychosocial support, cognitive behavioral therapy, cognitive training, relaxation (including exercises, eg, progressive muscle relaxation), stress management, general goal setting, mood disturbance, handling emotions (how to cope with the disease), psychosocial problems associated with respiratory disability, self-talk and panic control, health qigong
Preventative	Avoiding exacerbations, pollution and environmental hazards, managing infections, and personal hygiene
Inhaler technique and use	Assessing inhaler technique, teaching correct use, and handling of inhalers
Energy conservation	Pacing and good posture, home modifications and activities of daily living, work simplification
Support groups/patient empowerment	Peer support self-help groups/networks, eg, Breathe Easy, developing confidence to negotiate with clinicians
Exercise – strength	Upper limb, lower limb strength/resistance exercises
Exercise – aerobic	Cycling, walking, stair climbing as aerobic/endurance exercises
Exercise – other	Flexibility and balance exercises, sham training, unspecified exercises
Enhanced access/care	Access to health professionals, access to call center/hotline, health professional home visits and/or telephone support
Other	Any miscellaneous uncommon components, eg, sleep or other symptom control
Usual care	Usual medications and visits to general practitioner or routine secondary care

Table S2 Content of interventions by the number of components within the self-management package

	Number of self-management components in intervention													Total number of interventions (% of comparisons)a
	1	2	3	4	5	6	7	8	9	10	11	12	13
Action planning for self-treating exacerbations	0	3	2	2	4	2	7	6	4	7	3	3	1	43 (19.0)
Breathing techniques/dyspnea management	2	37	16	15	10	18	16	12	5	7	5	24	1	146 (64.6)
Bronchial hygiene/secretion clearance techniques	0	0	0	4	2	3	5	4	1	3	5	2	1	30 (13.3)
Disease knowledge	0	8	11	10	14	17	16	13	4	7	5	2	1	108 (47.8)
Energy conservation	0	0	0	2	0	3	1	8	1	2	4	1	0	22 (9.7)
Enhanced access	0	4	6	3	6	4	8	7	3	4	3	1	1	50 (22.1)
Exercise	25	37	21	14	10	18	17	14	5	7	5	2	1	176 (77.9)
Inhaler technique	0	0	0	1	2	4	8	7	4	5	2	2	1	36 (15.9)
Medication advice	0	1	6	3	7	16	13	13	5	6	5	1	1	77 (34.1)
Nutrition advice	0	2	3	1	4	8	10	6	4	5	5	2	1	51 (22.6)
Preventative measures to avoid infection	0	0	3	0	0	2	2	3	2	2	2	1	1	18 (8.0)
Psychological including relaxation and stress management	1	3	8	14	8	14	8	7	2	4	5	2	1	77 (34.0)
Respiratory muscle training	9	7	7	1	0	3	4	0	0	0	1	0	0	32 (14.2)
Smoking cessation advice/support	0	0	0	1	5	6	9	8	4	5	3	2	1	44 (19.5)
COPD support groups	0	0	0	0	1	2	1	1	0	1	0	1	0	7 (3.1)
Unspecified	0	0	1	4	3	6	0	3	0	4	1	1	1	24 (10.6)
Other	0	6	3	1	4	0	1	0	1	1	1	0	0	18 (7.7)

Note:

a n=226 comparison groups.