Self-management education for patients with chronic obstructive pulmonary disease

 

Abstract

Background

There is great interest in chronic obstructive pulmonary disease (COPD) and the associated large burden of disease. COPD is characterised by frequent day by day fluctuations, and repetitive clinical exacerbations are typical. Self-management is a term applied to educational programmes aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behaviour change, and provide emotional support for patients to control their disease and live functional lives. In COPD, the value of self-management education is not yet clear. The first Cochrane review about self-management was published in 2003. It was intended to shed light on the effectiveness of self-management programmes in COPD and the relative efficacy of their constitutive elements. No conclusions about the effectiveness of self-management could be drawn because of the large variation in outcome measures used in the limited number of included studies. This article describes the first update of this review.

Objectives

The objective of this review was to assess the settings, methods and efficacy of COPD self-management education programmes on health outcomes and use of health care services.

Search methods

We searched the Cochrane Airways Group trial register, MEDLINE (January 1985 to January 2006), reference lists, and abstracts of medical conferences.

Selection criteria

Controlled trials (randomised and non-randomised) of self-management education in patients with COPD. Studies focusing mainly on pulmonary rehabilitation and studies without usual care as a control group were excluded.

Data collection and analysis

Two reviewers independently assessed study quality and extracted data. Investigators were contacted for additional information.

Main results

The reviewers included 15 group comparisons drawn from 14 trials. They assessed a broad-spectrum of interventions and health outcomes with different follow-up times. Meta-analyses could often not appropriately be performed because of heterogeneity among studies. The studies showed a significant reduction in the probability of at least one hospital admission among patients receiving self-management education compared to those receiving usual care (OR 0.64; 95% CI (0.47 to 0.89)). This translates into a one year NNT ranging from 10 (6 to 35) for patients with a 51% risk of exacerbation, to an NNT of 24 (16 to 80) for patients with a 13% risk of exacerbation. On the disease specific SGRQ, differences reached statistical significance at the 5% level on the total score (WMD -2.58; 95% CI (-5.14 to -0.02)) and impact domain (WMD -2.83; 95% CI (-5.65 to -0.02)), but these difference did not reach the clinically relevant improvement of 4 points. A small but significant reduction was detected in dyspnoea measured with the BORG-scale (WMD -0.53; 95% CI (-0.96 to -0.10)). No significant effects were found either in number of exacerbations, emergency department visits, lung function, exercise capacity, and days lost from work. Inconclusive results were observed in doctor and nurse visits, on symptoms other than dyspnoea, the use of courses of oral corticosteroids and antibiotics, and the use of rescue medication.

Authors' conclusions

It is likely that self-management education is associated with a reduction in hospital admissions with no indications for detrimental effects in other outcome parameters. This would in itself already be enough reason for recommending self-management education in COPD. However, because of heterogeneity in interventions, study populations, follow-up time, and outcome measures, data are still insufficient to formulate clear recommendations regarding the form and contents of self-management education programmes in COPD. There is an evident need for more large RCTs with a long-term follow-up, before more conclusions can be drawn.

 

Plain language summary

Self-management education for patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterised by frequent day by day fluctuations and repeated severe exacerbations are common. The idea of self-management is to teach patients the skills needed to carry out medical regimens specific to COPD, guide health behaviour change, and provide emotional support for patients to control their disease. It is not clear, however, what the influence of self-management education is in patients with COPD. The medical literature was systematically searched for studies assessing the effects of self-management education in COPD. Self-management reduces hospital admissions. However, because of heterogeneity in interventions, study populations, follow-up time, and outcome measures, data are still insufficient to formulate clear recommendations regarding the form and contents of self-management education programmes in COPD. There is an evident need for more large RCTs with a long-term follow-up, before more conclusions can be drawn.

 

摘要

背景

慢性阻塞性肺病患者的自我管理衛教

我們對慢性阻塞性肺病(COPD) 和此疾病相關的重大負擔有很大的興趣。COPD 的特點是經常每天都會有變化，以及典型的重複臨床發作。自我管理是衛生教育計畫使用的一個詞彙，目的是教導病患執行該疾病專有的醫療技術、導引改變健康行為、和提供病患情緒支援等，以控制他們的疾病，和過一個有功能的生活。對於COPD，自我管理衛教的價值還不清楚。第一篇Cochrane 關於自我管理的討論文章是2003 年發表。其目的是要闡明COPD 自我管理計畫的效果，以及它們的各個組成元素的相對有效性。因為所選入的研究數量有限，所使用的結果測量值變化很大，所以無法對自我管理的效果下結論。本文敘述本討論文章的第一次更新版。

目標

本討論文章的目的是要評估醫療機構、COPD 自我管理衛教計畫對健康結果和健康照顧服務使用上的方法和功效。

搜尋策略

我們搜尋了Cochrane Airways Group trial register,、MEDLINE (1985 年 1 月到 2006 年 1 月)、參考資料清單、和醫學會議摘要等。

選擇標準

COPD 病患自我管理衛教的對照試驗(隨機和非隨機)。這些研究主要專注於肺臟復健，而沒有以一般照顧當對照組的研究會排除掉。

資料收集與分析

兩位審查員各自獨立評估研究品質和擷取數據。需要更多的資料則連絡研究人員。

主要結論

本篇討論文章從14 項試驗中選取15 組比較。它們評估了廣泛的介入和不同追蹤時間的健康結果。因為研究之間的歧異性，可能常會無法適當地進行綜合分析。這些研究顯示，與接受一般照顧的病患相比，接受自我管理衛教的病患顯著減少至少1 次住院的機率(危險對比值 [OR] 0.64；95% 信賴區間0.47 到 0.89)。當轉換成 1 年需要治療數(NNT) 時，則其範圍為：有51% 發作風險的病患，1 年需要治療數為10 (6 到 35) ，到有 13% 發作風險的病患，需要治療數24 (16 到 80)。在疾病專一的聖喬治呼吸問卷(SGRQ) 方面，總分數和影響範圍(impact domain) 的差異都達到5% 水準的統計顯著性，分別是總分數(加權均數差 [WMD] 2.58；95% 信賴區間5.14 到 0.02) 和影響範圍 (加權均數差 2.83；95% 信賴區間5.65 到 0.02)，但是這些差異都沒有達到4 分的臨床相關改善。使用BORGscale 測量呼吸困難，檢測到一個不大但有意義的減輕(加權均數差 0.53；95% 信賴區間0.96 到 0.10)。在發作次數、急診室就醫、肺功能、運動能力、和無法工作的天數等方面影響都無顯著性。在醫師和護士查房、呼吸困難除外的症狀、口服皮質類固醇和抗生素的使用療程、及急救藥物的使用等方面，結果都沒有定論。

作者結論

自我管理衛教計畫有可能與住院減少有關，且對其他結果參數沒有顯示有不好的影響。這可能已經有足夠理由來推薦COPD 自我管理衛教計畫。然而，因為介入方法、研究人口群、追蹤時間、和結果測量方法等的歧異性，所以數據仍不足以對COPD 自我管理衛教計畫的形式和內容，形成清楚的建議。很明顯地在下更多的結論前，還需要有更大型、長期追蹤的隨機對照試驗。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

COPD 的特點是經常每天都會有變化，而且常會重複嚴重發作。自我管理的概念是教導病患執行COPD 專有的醫療技術、導引改變健康行為、和提供病患情緒支援等，以控制他們的疾病。對於COPD 病患，自我管理衛教的影響還不清楚。我們系統地搜尋醫學文獻，以評估COPD 自我管理衛教的影響。自我管理能減少住院。然而，因為介入方法、研究人口群、追蹤時間、和結果測量方法等的歧異性，所以數據仍不足以對COPD 自我管理衛教計畫的形式和內容，形成清楚的建議。很明顯地在下更多的結論前，還需要有更大型、長期追蹤的隨機對照試驗。