Unravelling self-management for COPD

The principle of self-management emerged in the latter half of the 20th century as an important strategy for improving care for long-term conditions. ¹ While programmes for some chronic conditions such as diabetes are well established, ² the evidence in chronic obstructive pulmonary disease (COPD) is less clear.

Effing et al. ³ used an interesting approach of preparing a panel of experts in the field to collaborate thoughts, opinions and appraisal of the literature. The article highlights important features of self-management and identifies areas for development. It is an important task for those with interest and expertise in the subject to reach conformity and bring greater clarity to the terminologies, content and processes which are involved in order to move forward.

The authors have reasoned that the evidence for self-management in COPD is currently fragmented. ⁴ There is large variability in the nature of the interventions, outcome measures and time to follow-up. For instance, while some programmes have included no formal exercise at all, ^5,6 others have incorporated up to 12 months of supervised exercise ⁷ ; and while some programmes provided education as a one-off event, ⁸ others were extended over much longer periods. ⁹ Intuitively one may expect that higher levels of supervision might prosper better outcomes. However, we have seen that some programmes with only minimal supervision have had significant impact on health care utilisation and health status. ¹⁰

Another consideration is that some of the extended programmes branded as ‘self-management’ actually exceed the level of support that many comprehensive pulmonary rehabilitation programmes offer. The COPE studies ^7,9 provided individuals with up to twice weekly supervised exercise for up to a year, which surpasses the 6–8 weeks provided by many rehabilitation courses reported in the literature.

As the authors of this article have identified, self-management sits along a continuum of care, and the level of support provided should be decided based upon the individual’s needs. It seems prudent that the least severe patients could be provided with a more simple approach to self-management and that support should be increased as the complexity of the individual’s requirements escalates. This would be a tiered approach to self-management demonstrated in Figure 1.

Figure 1.

A spectrum of support for chronic obstructive pulmonary disease (COPD).

This model might offer further clarification on the content and processes by which various levels of support are achieved. It aids definition of terms and may help practitioners identify individual’s needs and the level of care which is required. Health professionals interested in the field might use this tool to help construct interventions, identify appropriate outcome measures and define the intervention in a standardised way. As suggested by Effing et al., ³ for the most severe patients the most comprehensive pulmonary rehabilitation programme which includes self-management should be of importance, that is ‘Integrated Care’. For less complicated individuals whose needs are most basic, the minimal ‘action plan’ intervention may be sufficient.

In the face of a progressive disease, long-term maintenance of health status is challenging. While the immediate effects of pulmonary rehabilitation programmes are widely recognised, how to maintain them has been questioned. ¹¹ Effing and colleagues ³ have commended change in behaviour as the only way health status improvements can be sustained. Cognitive behavioural techniques have been proposed as therapies which may be fundamental to facilitating behaviour change. Two studies which have incorporated motivational interviewing into self-management interventions have both shown successful improvements in quality of life at 12 months. ^10,12 The study by Khdour and colleagues ¹⁰ is of particular interest because it also demonstrated reduced health care utilisation, despite the intervention only requiring 1 h of supervision. The incorporation of psychological techniques into self-management programmes is certainly an area for further attention.

Self-efficacy has been acknowledged in the article as an important aspect of behaviour change. By identifying deficits in self-efficacy and manipulating it, behaviour change might be more successful. As Effing et al. ³ have identified there has been a lack of tools available, which is evident in the literature which largely fails to measure it. Perhaps the newly validated PRAISE tool ¹³ which measures self-efficacy for those entering rehabilitation might be suitable for some self-management programmes.

This review offers a useful summation of the current status of self-management for COPD and makes recommendations in order to bring greater cohesion to the subject. For those considering developing COPD self-management programmes, this article proposes suggestions which may help the progression of research in a more uniformed direction upon which greater conclusions about programme choices can be made.