Evelyn Monninkhof

Self-management education for patients with chronic obstructive pulmonary disease: a systematic review

Background: The idea of self-management is to teach patients how to carry out the activities of daily living optimally in the face of their physiological impairment, and to prevent or decrease the severity of exacerbations by means of life style adaptation. In chronic obstructive pulmonary disease (COPD) the value of self-management education is not clear. This review was undertaken to clarify the effectiveness of self-management programmes in COPD. Methods: A search was made of the Cochrane Airways Group trial registers, Medline, reference lists, and abstracts of medical conferences for controlled trials of self-management education in patients with COPD. Two reviewers independently assessed each paper for methodological quality and extracted the data. Results: The reviewers included 12 articles describing eight randomised controlled trials and one controlled clinical trial in which self-management education was compared with usual care. The studies assessed a broad spectrum of outcome measures with different follow up times so meta-analysis could not be undertaken. Self-management education had no effect on hospital admissions, emergency room visits, days lost from work, and lung function. Inconclusive results were observed on health related quality of life, COPD symptoms, and use of healthcare facilities such as doctor and nurse visits. Self-management education reduced the need for rescue medication and led to increased use of courses of oral steroids and antibiotics for respiratory symptoms. Conclusions: Insufficient data were obtained to make recommendations because of the wide variation in outcome measures used and other limitations to generalisations in the current published literature. Further research in this area is needed.

Self-management education for chronic obstructive pulmonary disease.

BACKGROUNDnIn asthma, self-management programmes have been proven to be effective. In COPD, their value is not clear.nnnOBJECTIVESnTo assess the efficacy of COPD self-management/ education programmes on health outcomes and use of health servicesnnnSEARCH STRATEGYnWe searched the Cochrane Airways Group trial registers, MEDLINE (January 1985 to October 2001), reference lists, and abstracts of medical conferences. We also contacted research groups in the field for ongoing trials and unpublished material.nnnSELECTION CRITERIAnControlled trials (randomised and non-randomised) of self-management education in patients with COPD. Studies focusing mainly on physical pulmonary rehabilitation were excluded.nnnDATA COLLECTION AND ANALYSISnTwo reviewers independently assessed trial quality and extracted data. Investigators were contacted for additional information.nnnMAIN RESULTSnThe reviewers included 12 articles describing 8 randomised-controlled trials and 1 controlled clinical trial. Self-management education was compared with usual care in 8 studies. The studies in this review assessed a broad-spectrum of outcome measures with different follow-up times. Synthesis of the results using meta-analysis was always not possible. The studies showed no effect of self-management education on hospital admissions, emergency room visits, days lost from work and lung function. Inconclusive results were observed on health-related quality of life (HRQoL): studies using the disease specific SGRQ showed a better quality of life in the patients in the intervention group, but only in the activity component where there was heterogeneity between the results of the two included studies. A potential reason for the absence of convincing effects on HRQoL is the limited use of COPD-specific instruments. Inconclusive results were observed on COPD-symptoms and use of other health care resources such as doctor and nurse visits. Self-management education reduced the need for rescue medication, and led to an increased use of courses of oral steroids and antibiotics for respiratory symptoms.nnnREVIEWERS CONCLUSIONSnThe data available for this review are insufficient for forming recommendations. Further research on the effectiveness of self-management programmes should be focussed on behavioural change evaluated in well designed randomised controlled trials with standardised outcomes designed for use in COPD patients, and with long follow-up time so that definite conclusions can be made.

Clinical predictors of bacterial involvement in exacerbations of chronic obstructive pulmonary disease.

BACKGROUNDnThe wide use of antibiotics for treatment of exacerbations of chronic obstructive pulmonary disease (COPD) lacks evidence. The efficacy is debatable, and bacterial involvement in exacerbation is difficult to verify. The aim of this prospective study was to identify factors that can help to estimate the probability that a microorganism is involved in exacerbation of COPD and, therefore, predict the success of antibiotic treatment.nnnMETHODSnClinical data and sputum samples were obtained from 116 patients during exacerbation of COPD. Bacterial infection was defined by the abundant presence of >or=1 potential pathological microorganism in relation to the normal flora in sputum.nnnRESULTSnOf 116 exacerbations, 22 (19%) had bacterial involvement. The combination of a negative result of a sputum Gram stain, a relevant nonclinical decrease in lung function (compared with baseline measurements), and occurrence of <2 exacerbations in the previous year were 100% predictive of a nonbacterial origin of the exacerbation. The presence of all 3 of these clinical characteristics yielded a positive predictive value of 67% for a bacterial exacerbation.nnnCONCLUSIONSnPatients presenting with an exacerbation who have a negative result of sputum Gram stain, do not have a clinically relevant decrease in lung function, and have experienced <2 exacerbations of COPD in the previous year do not require antibiotic treatment [corrected]. A treatment protocol taking into account these variables might lead to a 5%-24% reduction in unnecessary treatment with antibiotics, depending on actual prescription rates.

The effect of a minimal contact smoking cessation programme in out-patients with chronic obstructive pulmonary disease: a pre-post-test study.

This study assessed the efficacy of an individual, minimal contact, smoking cessation programme in chronic obstructive pulmonary disease (COPD) patients, using a pre-post-test design. The study was part of a large ongoing investigation into the efficacy of self-management in patients with COPD (the COPE-study). In total, the participants received three 15-30 min home-based counselling sessions. Additionally, patients were provided with a written self-help manual. On the patients request, the chest physician prescribed bupropion or nicotine replacement therapy (NRT). Cessation rates after nine months were based on self-report, and afterwards confirmed by salivary cotinine analysis. Patients were biochemically classified as smoker if their cotinine levels exceeded 20 ng/ml. At baseline, one third of the 269 patients in the COPE-study were active smokers (according to self-report). Almost 70% (n=64) of these patients were willing to participate in the smoking cessation program. After nine months follow-up, 23 (36.5%) patients self-reported abstinence. However, the cotinine validated abstinence rate was much lower: 12.7% (n=8), implying that the actual abstinence rate is severely overestimated by self-report in this study. The results suggest that the (validated) effectiveness of this intervention is probably in line with that of comparable programmes for healthy persons. However, considering the urgent need for quitting in COPD patients, a more intensive programme resulting in higher quit rates, seems to be required for this high-risk population.

Management of stable COPD.

Chronic obstructive pulmonary disease (COPD) is a systemic disease with major impact worldwide. In the treatment of COPD a holistic approach should be taken. In order to reach this, an individual treatment plan should be made which includes at least elements of smoking cessation, optimisation of pulmonary status by pharmacotherapy and exercise embedded in a new lifestyle. Furthermore, more research on nutritional and metabolic intervention strategies for COPD patients is needed. With the availability of all these treatment options, a nihilistic attitude toward the patient with COPD is no longer justified.

Cost effectiveness of inhaled steroid withdrawal in outpatients with chronic obstructive pulmonary disease

Background: The evidence for the effectiveness and safety of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) is inconclusive. This study determined the cost effectiveness of withdrawing fluticasone propionate (FP) in outpatients with COPD. Methods: The cost effectiveness analysis was based on a randomised, placebo controlled FP withdrawal study. After a 4 month run in period on FP, patients were randomly assigned to continue FP 500 μg twice daily or to receive placebo for 6 months. A decision analytical model evaluated the 6 month incremental cost effectiveness of the ICS versus ICS withdrawal strategy. One way sensitivity analyses and a Monte Carlo simulation were performed to evaluate the robustness of the findings. Results: The average patient with COPD in the FP group generated €511 in direct medical costs, including €238 for FP. The cost of the placebo strategy was €456. The higher direct drug cost of €212 per patient for the FP strategy during the 6 month follow up period compared with the placebo group was partially offset by a lower exacerbation and hospital admission cost of €157. The 6 month incremental cost effectiveness of the FP strategy compared with placebo was €110 per exacerbation prevented and €1286 per hospital admission prevented. Conclusions: Over a 6 month period, withdrawing FP in a pre-selected trial population of COPD patients led to absolute cost savings but with a higher rate of exacerbations and hospital admissions.

Managing COPD: no more nihilism!

This special issue of Patient Education and Counseling is long overdue. During most of the last two decades asthma, and notably asthma self-management has been in the spotlight, while COPD has had to endure a nihilistic approach. The first sign that interest was shifting to the treatment of COPD came from a few large randomized trials on the use of inhaled corticosteroids (ICS) in COPD. Although these studies demonstrated a moderate effect of ICS in COPD, it has become clear that true improvements in the management of this chronic disease will have to come from behavioral interventions. This special issue of Patient Education and Counseling is dedicated solely to the non-pharmaceutical management of COPD. It addresses many issues related to behavioral therapy, such as smoking cessation, exercise training, nutritional aspects, and self-management programs, including action plans to self-treat exacerbations. With the availability of all the treatment and management options, described in this special issue, a nihilistic attitude toward the patient with COPD is no longer justified.