A systematic review of the evidence of the effectiveness of community-based interventions to support self-management among primary care COPD patients

Problem

Systematic reviews have shown that self-management education and integrated care for COPD reduce hospital admissions and improve health related quality of life (HRQoL). However, self-management trials are very heterogenous in intervention content, population and comparator and have largely included participants identified from secondary care. This systematic review aimed to determine the effectiveness of self-management interventions in primary care patients with COPD.

Approach

A systematic review of randomised controlled trials was undertaken using a comprehensive search strategy from the inception of each electronic database until May 2012 for trials with: population: people with a diagnosis of COPD recruited from primary care; intervention: support for COPD self-management; comparator groups: usual care, a control group, sham intervention or other self-management intervention; primary outcome: HRQoL; other outcomes: anxiety, depression, health care utilisation, exacerbations, exercise capacity, lung function, dyspnoea. An updated search focussed on primary care was undertaken to July 2016.Self-management was defined as a structured intervention aimed at improvement of self-management health behaviours and self-management skills. It had to include an iterative process of interaction between participant and healthcare provider, and ideally also included formulation of goals and provision of feedback and required at least two contacts. At least two of the following components had to be part of the intervention: smoking cessation, self-recognition/self-treatment of exacerbations, an exercise or physical activity component, advice about diet medication or coping with breathlessness.Study selection was undertaken independently in duplicate. Data extraction and risk of bias assessment were carried out by one reviewer with a sample checked by a second. Meta-analyses were undertaken using random effects meta-analysis. This review is registered on PROSPERO as CRD4206043958.

Findings

From 12,146 abstracts, we identified twelve eligible papers reporting twelve RCTs with 12,090 participants. Of the 12 included trials, 7 had data that we included in meta-analyses. Trials ranged in size from 52 to 8217 participants, with last follow-up from 3 months to 4 years; 3 UK based. The self-management interventions were heterogeneous; duration ranged from 4 weeks to 2 years and were delivered by GPs, nurses, physiotherapists and trained peers. There was no difference in health-related quality of life (HRQoL) at last follow-up (St Georges Respiratory Questionnaire total score -0.19, (95%CI -1.28 to 0.89; I2 0%), nor any difference in the domains of the CRQ (Chronic Respiratory Questionnaire). Anxiety was significantly lower in the self-management group: HADS anxiety -0.85 (95%CI -1.22 to -0.48; I2 16.9%).

Consequences

Self-management interventions for COPD in primary care show promise in reducing patient anxiety, but no effect on HRQoL. The heterogeneity of outcome measures used meant synthesis of the full evidence was not possible.