Effectiveness of chronic obstructive pulmonary disease self-management interventions in primary care settings: a systematic review

Chronic obstructive pulmonary disease (COPD) is one of the major disabling diseases and the third cause of mortality worldwide (World Health Organization 2018). It is one of the top 10 diseases frequently referred from primary care to hospitals (Britt et al. 2015). During last decades, several efforts have been made to control COPD progression through the development of efficient self-management programs or interventions. The most recent Cochrane systematic reviews have reported that well-supported self-management interventions are effective in decreasing COPD hospital admissions and improving health-related quality of life (Majothi et al. 2015). ‘Self-management’ refers to ‘the ability of a patient to deal with all that a chronic disease entails, including symptoms, treatment, physical and social consequences and lifestyle changes’ (Barlow et al. 2002). COPD self-management requires improved COPD knowledge, self-recognition of symptoms, smoking cessation, physical activity, medication adherence, the correct use of inhalers and correct breathing techniques, as well as self-efficacy (Effing et al. 2016). Self-efficacy refers to an individual’s belief in the ability to execute the courses of action required to accomplish or manage a task. Self-efficacy is a major driver of self-management behaviour as it enables individuals to deal with challenges despite barriers that may undermine motivation (Guo et al. 2017).

The majority of COPD self-management interventions have focussed on COPD patients in secondary and tertiary care settings following hospitalisation. Few efforts have been made to improve COPD self-management outcomes in primary care settings (Fromer 2011). Primary care is the first contact point between patients and healthcare system and is the best place to intervene with COPD process at an early stage and prevent the burden of managing advanced stages of the disease. However, the effectiveness of self-management interventions on COPD patients in the primary care setting is still uncertain (Mitchell et al. 2014). This systematic review therefore intends to summarise the available evidence regarding the effectiveness of self-management interventions on patient’s COPD knowledge and skills in primary care settings.

The literature was searched to identify COPD self-management trials in primary care settings undertaken since 2001 until July 2018 (Fig. 1). The year 2001 was selected to ensure studies complied with the updated COPD management guidelines. Search terms included COPD or chronic bronchitis or pulmonary emphysema, self-management and primary care or general practice (Box 1). Online databases searched included Social Sciences, Citation Index, MEDLINE, CINAHL, Academic Search Complete and Scopus. The literature search identified 1089 potential studies. After removing duplications (290), 400 studies were also removed as they were not randomised controlled trials (RCT) and did not study primary care patients. The remaining 399 studies were assessed for eligibility. Titles and abstracts were reviewed against the inclusion criteria, and only 23 studies met the selection criteria. The full-text of the remaining 23 studies were further assessed against the inclusion criteria and 13 studies were excluded. Finally, 10 trials were included in the review (Fig. 1).

Fig. 1.  Flow chart for study search and selection for inclusion.

Only RCTs were included in this review. Inclusion and exclusion criteria are described in Table 1. Trials were included if they were conducted in a primary care setting, measured self-management outcomes and published in English. Trials were excluded if they were undertaken in secondary or tertiary care settings and solely focussed on clinical measures. Decisions on study selection based on the inclusion and exclusion criteria were made independently by the authors. Disagreements were resolved by discussion. After that, data were extracted and tabulated by one author and then was double checked by the second author. The quality of the trials was assessed using Cochrane Back Review Group assessment criteria (Furlan et al. 2009).

Table 1.  Inclusion and exclusion criteria

Primary care COPD self-management trials measuring improvement in COPD knowledge, self-management behaviours like physical activity and smoking cessation, mental health, self-efficacy and self-management endpoint outcomes like hospitalisation and quality of life, were reviewed using a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol (Moher et al. 2009). A narrative synthesis was used to organise the literature due to variability in reporting the outcomes of the studies. Quality of the included studies were assessed using Cochrane Back Review Group (CBRG) assessment criteria (Furlan et al. 2009). Only high-quality trials scoring six CBRG points or more were included.

The initial search process resulted in 799 articles found. After scanning titles and abstracts, 23 articles remained as potentially relevant trials for full-text reading, of which 10 RCTs were found eligible for the final review.

The demographics of the participants in the trials are described in Table 2. The proportion of males and females varied between the trials, but most of the participants were male. The age of participants ranged between 18 and 81 years. In terms of sample size, it ranged between 52 and 6221 patients.

Table 2.  Characteristics of the eligible studies for the review
Data are presented as n unless otherwise stated. COPD, chronic obstructive pulmonary disease; QoL, quality of life; M, male; F, female

Components of the reviewed trials are depicted in Table 2. The trials included different levels of education delivered using different methods such as telephone mentoring (Walters et al. 2013; Jolly et al. 2018); face-to-face sessions (Efraimsson et al. 2008; Bischoff et al. 2012; Taylor et al. 2012; Lou et al. 2015); or mix methods (McGeoch et al. 2006; Zwar et al. 2012; Mitchell et al. 2014).

The educational component of the trials often covered smoking cessation counselling; breathing and coughing skills; mental health education; exacerbation symptoms recognition and management; improving physical activity levels; the correct use of inhalers; and medication compliance. The duration of the education sessions varied between 6 weeks and 4 years. All of the trials were tailored to the participants’ needs.

Only Mitchell et al. (2014) and Jolly et al. (2018) had provided an exercise program; however, it was not supervised. Bischoff et al. (2012) did not provide any exercise program or physical activity education. Three trials used motivational interviewing methods and participants were encouraged to set goals, follow up and provide with further support to comply with the intervention (Taylor et al. 2012; Zwar et al. 2012; Jolly et al. 2018).

Three trials involved more complex and integrated self-management programs, whereby multidisciplinary health teams were involved (Bischoff et al. 2012; Mitchell et al. 2014; Lou et al. 2015). Bischoff et al. (2012) and McGeoch et al. (2006) mainly targeted improving self-recognition and self-treatment of exacerbation symptoms.

The interventions were often carried out by health professionals, mainly nurses and physiotherapists; the exception being the study by Taylor et al. (2012) whereby trained lay persons conducted the interventions. The trials conducted by Kruis et al. (2014) and Lou et al. (2015) involved multidisciplinary teams consisting of physicians, social workers, nurses and dietitians.

The duration of the interventions varied from 6 weeks (Mitchell et al. 2014) to 4 years (Lou et al. 2015).

Only high-quality trials scoring the highest score (six points or more) based on Cochrane Back Review Group assessment criteria (Furlan et al. 2009) were selected. The majority of trials were single blinded. This might be explained by the fact that it is not often practical to blind healthcare practitioners as they are involved in delivering interventions. One trial was unblinded (McGeoch et al. 2006).

The effectiveness of the trials was assessed by measuring improvement in COPD self-management behaviours, COPD knowledge, self-efficacy and self-management endpoint outcomes such as hospitalisation rate and quality of life at baseline and at different intervals after the intervention. Tables 2 and 3 summarise the measured variables and achieved outcomes.

Table 3.  Summary of outcomes results
COPD, chronic obstructive pulmonary disease; BODE, Body mass index, airflow Obstruction, Dyspnoea, Exercise capacity

Six studies found statistically significant improvements in COPD knowledge among the intervention groups compared with the control groups (McGeoch et al. 2006; Efraimsson et al. 2008; Zwar et al. 2012; Walters et al. 2013; Mitchell et al. 2014; Lou et al. 2015). Four studies did not measure COPD knowledge (Bischoff et al. 2012; Taylor et al. 2012; Kruis et al. 2014; Jolly et al. 2018).

Six studies found no difference in self-efficacy either in the short term or long term (Bischoff et al. 2012; Taylor et al. 2012; Walters et al. 2013; Kruis et al. 2014; Mitchell et al. 2014; Jolly et al. 2018). Taylor et al. (2012) found some degree of improvement in self-efficacy in terms of communicating with doctors in the intervention group; however, patients in the control group had higher confidence in managing COPD.

Four trials had shown improvement in physical activity (Efraimsson et al. 2008; Taylor et al. 2012; Mitchell et al. 2014; Lou et al. 2015). Jolly et al. (2018) found statistically significant improvements in exercise level at a 6-month follow up, but it was diminished at a 12-month follow up. Zwar et al. (2012) and Kruis et al. (2014) found no improvement in physical activity level.

Three studies showed improvement in smoking cessation rate among the intervention groups (Efraimsson et al. 2008; Mitchell et al. 2014; Lou et al. 2015). Efraimsson et al. (2008) used spirometry as encouragement to quit smoking, which resulted in one-third of patients being able to quit. Whereas in other studies, there was no difference in the smoking cessation rate at the 6- and 12-month follow ups (Zwar et al. 2012; Kruis et al. 2014; Jolly et al. 2018).

Medication adherence and inhaler use techniques were improved in two studies (Lou et al. 2015; Jolly et al. 2018). In the trial by Jolly et al. (2018), medication compliance was statistically significant at 6 months, but it was not sustained at a12-month follow up. In contrast, correct inhaler use maintained at statistically significant at both the 6- and 12-month follow ups.

Action planning for exacerbation self-management showed improvement in recognition and management of exacerbation (McGeoch et al. 2006; Bischoff et al. 2012).

Four trials reported statistically significant improvement in mental health status through decreased depression and anxiety levels (Efraimsson et al. 2008; Taylor et al. 2012; Mitchell et al. 2014; Lou et al. 2015).

Only the trial by Lou et al. (2015) improved the hospitalisation rate and the trial by Taylor et al. (2012) led to a statistically significant improvement in the quality of life.

This systematic review analysed the effectiveness of 10 COPD self-management trials on COPD self-management outcomes in primary care settings. The interventions were heterogeneous in terms of contents, duration, intensity, severity of the disease, frequency of follow ups, methods of delivery and healthcare disciplines involved. Some trials involved only education and action planning, whereas others involved more complex self-management programs (Bischoff et al. 2012; Mitchell et al. 2014; Lou et al. 2015). Only one trial involved an integrated disease management program (Kruis et al. 2014). Thus, the findings of this review should be interpreted with caution.

Patient education was an integral part of the all trials. This complies with the current guidelines that mandate education as a corner stone in COPD self-management programs (Wang et al. 2017). Our findings showed that the majority of interventions improved COPD knowledge and adherence to treatment and correct use of inhalers. There were also some improvements in patients’ mental health, especially in terms of anxiety level. Few interventions had a positive effect on physical activity and smoking cessation. These findings are consistent with the findings of other systematic reviews assessing the effects of self-management education (Effing et al. 2007; Wang et al. 2017).

We found that improvement in COPD knowledge does not always lead to improvement in self-management skills or behaviour (Jolly et al. 2018). This is in line with the literature, which indicates that health literacy and disease knowledge are not readily translated into self-management behaviours (Niknami et al. 2018). Despite compelling evidence suggesting that physical activity improves COPD management by reducing exacerbation (Dheda et al. 2004; Jolly et al. 2016), only two of the trials had incorporated limited unsupervised exercise programs (Mitchell et al. 2014; Jolly et al. 2018). The trials appeared to have some positive effects on exercise level. Our findings suggest that supervised physical activity programs are more likely to be more efficient (Jolly et al. 2016).

In line with previous systematic reviews (Wang et al. 2017), our findings suggest that self-management interventions can have some positive effects on the rate of smoking cessation (Efraimsson et al. 2008; Mitchell et al. 2014). Available literature suggests that using motivational behaviour-changing strategies is more likely to result in smoking cessation (Bartlett et al. 2014).

More importantly, the majority of the trials, especially those recruited stable patients with mild-to-moderate COPD, failed to improve self-efficacy, which is essential for both changing and maintaining self-management behaviours (Guo et al. 2017). This finding suggests that assessing patient readiness, especially among stable patients with mild-to-moderate disease, who are more likely to be motivated to follow self-management plans due to their relatively stable condition, is critical in improving the effectiveness of self-management interventions (Robinson et al. 2008).

We also found that the self-management trials lead to positive improvements in exacerbation self-recognition and management, which is critical in COPD management in primary care settings. This is in line with another systematic review, which found that action planning and brief education about the action plan are enough to improve exacerbation self-management skills (Howcroft et al. 2016).

In line with the literature (Jonkman et al. 2016), our findings suggest that more intense and frequent education interventions with frequent and long-term follow ups, combined with active patient engagement, are more likely to yield promising outcomes.

Finally, the trials were mainly unsuccessful in generating significant improvements in terms of COPD self-management endpoint outcomes, namely quality of life and hospitalisation rate. Only one trial improved the COPD hospitalisation rate (Lou et al. 2015) and one trial generated improvements in quality of life (Taylor et al. 2012). Improvement in quality of life and hospitalisation rate is critical for the cost effectiveness of COPD self-management trials in primary care. Our finding warrants further studies to find better strategies to improve COPD-related quality of life and hospitalisation rate to benefit both patients and the community.

Despite invaluable data obtained in this study, this systematic review has some limitations. The description of interventions, as well as reporting and analysis of the outcomes measurements, were not clear in all the trials. The heterogeneity of the interventions makes comparison very difficult. The professional background of those who administered the interventions could affect the quality of the information provided.

COPD self-management trials in primary care settings lead to more positive effects on knowledge than self-management behaviours. This might be explained by the fact that the trials were unable to improve self-efficacy, which is essential for translating knowledge to behaviour. Therefore, future studies should focus on improving self-efficacy to make sure patients have self-belief and capacity to execute the courses of action required to accomplish self-management tasks despite barriers undermining motivation (Guo et al. 2017).

More importantly, the trials failed to yield any significant improvement in quality of life and hospitalisation rate, which is vital for cost-effectiveness from a healthcare system point of view. This finding requires well-designed trials equipped with strategies aiming to improve endpoint outcomes such as quality of life and hospitalisation rate in primary care settings. Our analysis recommends that trials with a larger sample size, longer follow ups, validated outcome measurements and ongoing evaluation allowing frequent revisions of the intervention content and delivery methods are more likely to improve quality of life and hospitalisation rate (Lou et al. 2015).

The authors have no conflicts of interest to declare.