Chronic Obstructive Pulmonary Disease axis of the Respiratory Network Fonds de la Recherche en Sante du QuebecArch Intern Med. 2003;163:585-591.
Background: Self-management interventions improve various outcomes for many chronic diseases. The definite place of self-management in the care of chronic obstructive pulmonary disease (COPD) has not been established. We evaluated the effect of a continuum of self-management, specific to COPD, on the use of hospital services and health status among patients with moderate to severe disease.
Methods: A multicenter, randomized clinical trial was carried out in 7 hospitals from February 1998 to July 1999. All patients had advanced COPD with at least 1 hospitalization for exacerbation in the previous year. Patients were assigned to a self-management program or to usual care. The intervention consisted of a comprehensive patient education program administered through weekly visits by trained health professionals over a 2-month period with monthly telephone follow-up. Over 12 months, data were collected regarding the primary outcome and number of hospitalizations; secondary outcomes included emergency visits and patient health status.
Results: Hospital admissions for exacerbation of COPD were reduced by 39.8% in the intervention group compared with the usual care group (P = .01), and admissions for other health problems were reduced by 57.1% (P = .01). Emergency department visits were reduced by 41.0% (P = .02) and unscheduled physician visits by 58.9% (P = .003). Greater improvements in the impact subscale and total quality-of-life scores were observed in the intervention group at 4 months, although some of the benefits were maintained only for the impact score at 12 months.
Conclusions: A continuum of self-management for COPD patients provided by a trained health professional can significantly reduce the utilization of health care services and improve health status. This approach of care can be implemented within normal practice.
Comments: Although it is known that self-management programs can improve outcomes in several chronic disease states, the role of such programs in management of severe COPD is uncertain. In this multicenter, randomized, parallel group trial, patients were randomly assigned to receive either usual care or usual care plus a comprehensive disease-specific management plan that consisted of an extensive education program, a system of close contact with the healthcare providers and case manager, and home-based exercise. Patients were given specific instructions regarding management strategies for their baseline symptoms and their exacerbations. Patients in the self-management program had a 39.8% reduction in hospital admissions for acute exacerbations of COPD, a 41% reduction in emergency department AQ visits for acute exacerbations, and fewer unscheduled visits to their family physician. Health status also improved as a result of the intervention. This study demonstrates that a carefully designed and implemented self-management program can improve outcomes for patients with severe COPD. It should be noted that this study was conducted in Canada, where patients have access to universal healthcare coverage. A self-management system such as the one described in this study might be more difficult to implement in a healthcare environment without universal healthcare coverage.