Cochrane for Clinicians
Putting Evidence into Practice
Written Action Plans for Self-Management of COPD Exacerbations
Am Fam Physician. 2018 Mar 1;97(5):310-311.
Author disclosure: No relevant financial affiliations.
Do written action plans for self-management of chronic obstructive pulmonary disease (COPD) reduce the severity of acute exacerbations?
Written self-management plans, especially those that include guidance on smoking cessation, increase health-related quality of life in patients with COPD. They also decrease the need for respiratory-related hospital admissions among patients with high or low baseline risk.1 (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)
Self-management plans for patients with COPD have been shown to decrease respiratory- and all-cause–related hospitalizations and improve dyspnea and health-related quality of life.2 A recent recommendation suggests that COPD self-management should motivate, engage, and support patients to positively adapt their behaviors and develop skills to better manage their disease.3 The authors of this Cochrane review sought to demonstrate whether written management plans for COPD exacerbations would positively affect health-related quality of life and decrease the need for acute hospitalizations.1
This Cochrane review included 22 trials and 3,854 patients with COPD.1 Follow-up ranged from two to 24 months. The authors looked for studies in which the interventions included a written action plan, defined as an agreed strategy with actions to be initiated by a patient with COPD when symptoms deteriorate. Health-related quality of life was measured using the validated St. George's Respiratory Questionnaire (SGRQ)4; normal values on this assessment vary with sex and age, and lower scores represent better health-related quality of life. A change of four points is considered the minimal clinically important difference.
Patients who used a written action plan for COPD exacerbations had lower scores on the SGRQ compared with those receiving usual care (mean difference = 2.69 points; 95% confidence interval [CI], 0.9 to 4.49). This review also revealed a decreased need for respiratory-related hospital admissions among patients using written action plans, whether their baseline risk was high (number needed to treat [NNT] to prevent one admission in one year = 12; 95% CI, 7 to 69) or low (NNT to prevent one admission in one year = 17; 95% CI, 11 to 93). No differences were noted in the number of emergency department or outpatient clinic visits, or in dyspnea scores between patients who received a written action plan and those who received usual care.
Subgroup analysis showed that patients with COPD who participated in programs that included a written smoking cessation plan had an improvement in SGRQ scores of 4.98 points (95% CI, 2.78 to 7.17), whereas those who were involved in programs that did not include written smoking cessation plans had an improvement of only 1.33 points (95% CI, 0.27 to 2.94). Although the clinical significance is uncertain, very-low-quality evidence showed a small increase in respiratory-related mortality rates among patients receiving written intervention. The authors of this review posit that this result should be interpreted with caution, at the very least because a comparison of the all-cause mortality rates between the two groups did not reveal a difference.
SUMMARY TABLE: SELF-MANAGEMENT OF COPD EXACERBATIONS
|Outcomes||Probable outcome with written self-management plan||Probable outcome with usual care||NNT or NNH (95% CI)||Number of participants (number of studies)||Quality of evidence|
Respiratory-related hospital admissions (follow-up: 6 to 24 months)
238 per 1,000
312 per 1,000
13 (8 to 71)
All-cause hospital admissions (follow-up: 6 to 12 months)
356 per 1,000
427 per 1,000
All-cause mortality (follow-up: 3 to 24 months)
107 per 1,000
102 per 1,000
Referencesshow all references
1. Lenferink A, Brusse-Keizer M, van der Valk PD, et al. Self-management interventions including action plans for exacerbations versus usual care in patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017;(8):CD011682....
2. Zwerink M, Kerstjens HA, van der Palen J, et al. (Cost-) effectiveness of self-treatment of exacerbations in patients with COPD: 2 years follow-up of a RCT. Respirology. 2016;21(3):497–503.
3. Effing TW, Vercoulen JH, Bourbeau J, et al. Definition of a COPD self-management intervention: International Expert Group consensus. Eur Respir J. 2016;48(1):46–54.
4. St. George's Respiratory Questionnaire. http://www.healthstatus.sgul.ac.uk/SGRQ_download/Original%20English%20version.pdf. Accessed September 28, 2017.
5. Criner GJ, Bourbeau J, Diekemper RL, et al. Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society guideline. Chest. 2015;147(4):894–942.
These are summaries of reviews from the Cochrane Library.
This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.
A collection of Cochrane for Clinicians published in AFP is available at http://www.aafp.org/afp/cochrane.
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