Do self-management interventions in COPD patients work and which patients benefit most? An individual patient data meta-analysis.
BACKGROUND
Self-management interventions are considered effective in patients with COPD, but trials have shown inconsistent results and it is unknown which patients benefit most. This study aimed to summarize the evidence on effectiveness of self-management interventions and identify subgroups of COPD patients who benefit most.


METHODS
Randomized trials of self-management interventions between 1985 and 2013 were identified through a systematic literature search. Individual patient data of selected studies were requested from principal investigators and analyzed in an individual patient data meta-analysis using generalized mixed effects models.


RESULTS
Fourteen trials representing 3,282 patients were included. Self-management interventions improved health-related quality of life at 12 months (standardized mean difference 0.08, 95% confidence interval [CI] 0.00-0.16) and time to first respiratory-related hospitalization (hazard ratio 0.79, 95% CI 0.66-0.94) and all-cause hospitalization (hazard ratio 0.80, 95% CI 0.69-0.90), but had no effect on mortality. Prespecified subgroup analyses showed that interventions were more effective in males (6-month COPD-related hospitalization: interaction P=0.006), patients with severe lung function (6-month all-cause hospitalization: interaction P=0.016), moderate self-efficacy (12-month COPD-related hospitalization: interaction P=0.036), and high body mass index (6-month COPD-related hospitalization: interaction P=0.028 and 6-month mortality: interaction P=0.026). In none of these subgroups, a consistent effect was shown on all relevant outcomes.


CONCLUSIONS
Self-management interventions exert positive effects in patients with COPD on respiratory-related and all-cause hospitalizations and modest effects on 12-month health-related quality of life, supporting the implementation of self-management strategies in clinical practice. Benefits seem similar across the subgroups studied and limiting self-management interventions to specific patient subgroups cannot be recommended.
Department of Rehabilitation, Nursing Science and Sports.
Nini H
NH
Jonkman
Department of Rehabilitation, Nursing Science and Sports.
Heleen
H
Westland
Department of Rehabilitation, Nursing Science and Sports.
Jaap Ca
JC
Trappenburg
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht.
Rolf Hh
RH
Groenwold
Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands.
Erik Wma
EW
Bischoff
Respiratory Epidemiology and Clinical Research Unit, Department of Medicine, McGill University Health Center, McGill University, Montreal, QC, Canada.
Jean
J
Bourbeau
Department of Respiratory Medicine, Glasgow Royal Infirmary, Glasgow, UK.
Christine E
CE
Bucknall
Veterans Administration Portland Health Care System and Oregon Health & Science University, Portland, OR, USA.
David
D
Coultas
Department of Respiratory Medicine, Repatriation General Hospital, Adelaide, SA, Australia.
Tanja W
TW
Effing
Canterbury District Health Board, Respiratory Services, Christchurch Hospital, Christchurch, New Zealand.
Michael J
MJ
Epton
Department of Pulmonary Medicine, Sorlandet Hospital, Kristiansand, Norway.
Frode
F
Gallefoss
Centre for Research in Environmental Epidemiology CREAL; Pompeu Fabra University; CIBER Epidemiología y Salud Pública CIBERESP, Barcelona, Spain.
Judith
J
Garcia-Aymerich
Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK.
Suzanne M
SM
Lloyd
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht.
Evelyn M
EM
Monninkhof
Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
Huong Q
HQ
Nguyen
Department of Research Methodology, Measurement and Data Analysis, University of Twente; Department of Clinical Epidemiology, Medisch Spectrum Twente, Enschede, the Netherlands.
Job
J
van der Palen
Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Minneapolis Veterans Affairs Health Care Service and University of Minnesota, Minneapolis, MN, USA.
Kathryn L
KL
Rice
Respiratory Epidemiology and Clinical Research Unit, Department of Medicine, McGill University Health Center, McGill University, Montreal, QC, Canada.
Maria
M
Sedeno
Centre for Primary Care and Public Health, Queen Mary University of London, London, UK.
Stephanie Jc
SJ
Taylor
Department of Rehabilitation Sciences, Catholic University of Leuven, Leuven, Belgium.
Thierry
T
Troosters
School of Public Health and Community Medicine, UNSW Australia, Sydney, NSW, Australia.
Nicholas A
NA
Zwar
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht.
Arno W
AW
Hoes
Department of Rehabilitation, Nursing Science and Sports.
Marieke J
MJ
Schuurmans
D000368:Aged; D018450:Disease Progression; D019317:Evidence-Based Medicine; D005260:Female; D005541:Forced Expiratory Volume; D006760:Hospitalization; D006801:Humans; D008168:Lung / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D018579:Patient Selection; D029424:Pulmonary Disease, Chronic Obstructive / Q000401:mortality / Q000503:physiopathology / Q000523:psychology / Q000628:therapy*; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D020127:Recovery of Function; D012307:Risk Factors; D012648:Self Care / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome
chronic obstructive pulmonary disease; individual patient data meta-analysis; self-management; subgroup analysis