title: Action plans with limited patient education only for exacerbations of chronic obstructive pulmonary disease.
abstract: BACKGROUND
  Chronic obstructive pulmonary disease (COPD) is a progressive disease characterised by exacerbations, usually infective in origin, which affect symptoms and quality of life. Action plans may help individuals recognise a deterioration in their symptoms and initiate changes to treatment early, thereby reducing the impact of the exacerbation.
  
  
  OBJECTIVE
  To assess the efficacy of action plans in the management of COPD.
  
  
  METHODS
  We searched the Cochrane Airways Group Specialised Register (7 July 2009), CENTRAL, MEDLINE , CINAHL and ongoing trials registers (last searched July 2009).
  
  
  METHODS
  Randomised controlled trials of an individual action plan with minimal or no self management education, compared to control in patients with COPD were included. Studies in asthma and in multi-faceted interventions in which an action plan was combined with other elements such as education programme, exercise programme or outreach visits were excluded.
  
  
  METHODS
  Two reviewers independently assessed trial quality and extracted data. We contacted investigators for additional information when necessary.
  
  
  RESULTS
  Five studies enrolling 574 participants with moderate or severe COPD, with follow-up from six to twelve months, were included. There was no evidence that action plans reduced health care utilisation; assessed by hospital admission (mean difference (MD) 0.23; 95% CI -0.03 to 0.49), emergency department visits (MD 0.37; 95% CI -0.50 to 1.24) or GP visits (MD 0.53; -0.45, 1.50). Use of action plans was associated with increased initiation of treatment for acute exacerbations. Oral corticosteroid use was increased over 12 months (MD 0.74; 95% CI 0.14 to 1.35) with a significant increase in odds of being treated with antibiotics over 12 months (odds ratio 1.65; 95% CI 1.01 to 2.69). Self management knowledge and intention to initiate appropriate actions were improved in one study; recognition of a severe exacerbation (MD 2.50; 95% CI 1.04 to 3.96) and self initiating action in a severe exacerbation (MD 1.50; 95% CI 0.62 to 2.38). Health-related quality of life data were limited.
  
  
  CONCLUSIONS
  There is evidence that action plans with limited COPD education aid recognition of, and response to, an exacerbation with initiation of antibiotics and corticosteroids. Only one study measured patients' self health appropriate behaviour (decision making and taking action). There is no evidence of reduced healthcare resources utilisation or improved health-related quality of life.The practice of giving patients an action plan and limited self-management education for the management of COPD exacerbations, without a multi-faceted self-management program or ongoing case management cannot be recommended as the standard of care in COPD.
authors.affiliation: Menzies Research Institute, University of Tasmania, MS1, 17 Liverpool Street, PO Box 23, Hobart, Tasmania, Australia, 7001.
authors.forename: Julia Ae
authors.initials: JA
authors.lastname: Walters
authors.forename: Allison C
authors.initials: AC
authors.lastname: Turnock
authors.forename: E Haydn
authors.initials: EH
authors.lastname: Walters
authors.forename: Richard
authors.initials: R
authors.lastname: Wood-Baker
mesh_terms: D001521:Behavior Therapy; D006293:Health Promotion; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data; D006801:Humans; D010347:Patient Care Planning / Q000458:organization & administration*; D010353:Patient Education as Topic; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000628:therapy*; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012648:Self Care