What are the benefits of using self-management plans for COPD patients in the community: a critical review of the literature

Chronic obstructive pulmonary disease (COPD) is a disease of the airways that affects around 65 million people worldwide (World Health Organization, (WHO), 2020). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2022) defines COPD as a preventable and treatable condition that causes persistent respiratory symptoms and airflow obstruction. An abnormal inflammatory response to noxious gases and particles can be a catalyst for this condition (National Institute for Health and Care Excellence (NICE), 2018). The NHS is estimated to spend a total of £1.9 billion each year on COPD-related issues (NHS England, 2022); this is not accounting for the burden of the patient in the form of missed work, social isolation, psychological impact and the inability to maintain a good quality of life (QOL). Sargent and Boden (2006) indicated that proactive care, including self-management, are pivotal in the success of managing patients with COPD. Benefits include raising self-awareness and self-efficacy, which can hopefully reduce some of the costs faced by the patient.

Barlow et al (2002) defined self-management as the ability to manage symptoms, treatment and physical consequences of disease, while supporting lifestyle changes in managing one’s illness. A self-management approach in chronic disease aims to give people ownership and awareness of their condition; in turn, identifying early symptoms of exacerbation can commence prompt treatment, reduce admission to hospital and slow down the trajectory of disease progression (Jolly et al, 2018).

Self-management plans currently used in the author’s practice are adapted from the NICE (2018) guideline. These are patient-held collaborative plans and include instructions about exacerbation management. A superficial review of the literature reveals no recommended content for COPD management plans or information on how beneficial they are. Therefore, a systematic, critical review of the literature was carried out to highlight relevant data.

Methods

Literature search

A comprehensive search of the literature databases was performed to find all relevant papers to review (Erikson and Frandsen, 2018). Boolean Logic was used to carry out this search, enabling a refinement of search terms and combination of these terms. Search limits included a period between, and inclusive of, 2000-2019 and initially looked at papers from only the UK. However, widening the search to include international studies published in English allowed reviewing of a greater number of relevant papers.

The databases used in this critical review to source primary articles were British Nursing Index (BNI), Medline, CINAHL and the Cochrane Library. The emphasis was on using research from the original source; this is more favourable when performing a critical review, as this helps eliminate secondary source bias in the evaluation of a paper (Coughlan et al, 2014).

Additionally, a manual search of the reference lists from relevant research papers and systematic reviews, as well as searching for grey literature, was completed. Newell and Burnard (2011) and Bowers et al (2014) have suggested that grey literature, such as government documents and relevant guidelines, can be pertinent for current practice.

The search terms used were: ‘Chronic obstructive pulmonary disease’ OR ‘COPD’ OR ‘Respiratory disease’ OR ‘Pulmonary disease’ AND ‘Self-management plan’ OR ‘Self-management’ OR ‘Self-care’ AND ‘Community OR ‘Primary care’ OR ‘Home’. This search was completed and a wide range of papers were found. A primary review of the articles were done by briefly reviewing the title, article and abstract (Bowers et al, 2014). Due to the large number of articles found, the author decided to add Benefit* OR Advantage* OR Positive Outcome OR Positive Impact, to encompass a more tailored search in order to answer the research question.

When the search was completed, the abstracts of the papers were reviewed. This was considered an essential step to ensure that the paper met the criteria for inclusion, as, often, the titles can be misleading (Finfgeld-Connet and Johnson, 2013). Duplicate papers were also discarded.

Bootland et al (2017) suggested using a checklist to allow for reproducibility of assessment of the literature. The chosen tool was The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram (Moher et al, 2009) (Figure 1).

Using the McMaster checklist tool (Letts et al, 2007), eight studies were critically reviewed. It was anticipated that a thematic analysis would be used when analysing the research papers. This method was used for the identification, analysis and reporting of patterns within the data. Bryman (2016) suggested this is a common model for analysing qualitative data. This gives a flexible approach that can be used within different approaches to methodology. Williamson and Whittaker (2014) argue that thematic analysis can be used with the positivism approach to research. However, for the purpose of this article, it was decided to review key ideas that were been noted during the critique of each individual paper and document. These, along with the strengths and weakness of the studies, appear in tabular form (Table 1).

Inclusion/exclusion criteria

The qualitative and quantitative research was reviewed using the hierarchy of evidence (adapted by Howick, 2009) (Table 2), to eliminate inferior papers, including case-controlled studies (3b and 4), expert opinions and editorials (5). Randomized control trials (RCTs) are considered gold standard in quantitative research and were therefore included in the review. Qualitative studies that were considered applicable to the research question were also included in the review to provide patients’ perspectives (Straus et al, 2003).

Grey literature and studies based outside the UK were included with the prerequisite that they were published in English. Any evident cultural differences that were considered to affect the outcomes will be highlighted in the discussion. Furthermore, mixed method and observational studies will also be considered.

Non-English language papers were excluded due to risk of misinterpretation of primary data and bias in the translation. Self-management in multiple long-term conditions were also excluded as the focus of the review was solely on COPD.

Quantitative vs qualitative

Glasper and Rees (2013) suggested that there was still an assumption that quantitative methods are preferable to qualitative methods in health research. Arguably, a few years ago, qualitative studies in the hierarchy of evidence were poor in relation to answering evidence-based medical research. However, it is increasing due to a shift in the need to explore perspectives from groups and individuals. Green and Thorogood (2018) suggested that the best evidence would be what answers the research question most appropriately, Bowers et al (2014) agreed and indicated that qualitative research has become a more robust method of research in healthcare over the years.

Green and Thorogood (2018) argued that qualitative research design needs to have the same rigour and validity in sampling, data collection and analysis as quantitative research, and this will be analysed throughout the review.

Critical appraisal of papers needs the reader to adopt a critical thinking mindset and maintain an unbiased approach to remain impartial when reviewing the evidence presented in a paper (Bootland et al, 2017).

Ethical considerations

The ethical considerations for this review were minimal, as patients or staff were not directly involved.

Findings and results

Three qualitative studies were critiqued. Only one, Laue et al (2017), used a phenomenological design to address the views of patients. A second qualitative study by Williams et al (2014) explored patient’s experiences when using mobile technology in an exploratory method. This qualitative paper formed part of a large cohort study that was published separately. Finally, Davies et al (2014) completed a multinational study exploring the views of health professionals using self-management methods.

Of the five quantitative studies with RCTs, only one was a pilot. All five studies were multi-centred, over a longitudinal period. All the studies reviewed on the McMaster appraisal tool demonstrated procedural rigour by meeting most of the criteria set in the guidelines (Letts et al, 2007).

Qualitative papers

The studies have been summarised in Table 1. Laue et al (2017) conducted a phenomenological qualitative study to understand a patient’s perspective of self-treatment of acute exacerbation of COPD (AECOPD). The authors felt that 19 interviews were enough for data saturation. Four more participants were interviewed who had received medication after recruitment and interviewing had commenced.

Although 46 consent forms were signed, only 15 participants were contacted to arrange interviews. Changing the narrative of the study and interviewing other participants raises the question of a true representative sample, in turn, reducing the rigour and trustworthiness of the methods (Cho and Trent, 2006).

Key themes emerged from the interviews that were relevant to patients deciding to start self-treatment: ‘Knowing own body and illness’, ‘negotiating need for medication’, and ‘experiencing limitations of lay medical competence’. Patients’ decisions to start treatment had some barriers, which included symptom recognition. A further barrier was that patients did not always want to seek advice from a medical professional. Kessler et al (2006) and Trappenburg et al (2011) noted that patients who have a considerable knowledge base around their disease can promptly respond to treatment changes rather than seeking professional help.

Williams et al (2014) explored mobile technology and how this may assist in self-management techniques. When critiquing the paper, it was found to be part of a large cohort study. Patients were interviewed prior to, and after a 6-month timeframe. There were a total of 19 participants, of which, 15 participants took part in the post-study interview. This is a relatively small study and does highlight the need for further research with more participants.

The qualitative study looked at the perspectives of patients using mobile technology as an aim to improve management of COPD. The participants inputted information into the app as part of the research. The authors found those patients who participated less with the app were more reliant on health professionals for supportive management.

Davies et al (2014) conducted focus group discussions (FGD) in Europe and Hong Kong, China, involving 142 primary care physicians and pulmonologists. The aim of the study was to explore the views of the clinicians in using antibiotics and steroids as a self-treatment for AECOPD. There were three FGDs in each country. One with general practitioners (GPs) only, one with pulmonologists only and one with mixed professionals. A topic guide was used for each FGD; however, after FGD 1, the topic guide was revised based on preliminary data. Groups were led by university-employed researchers in the native language and most had an assistant moderator. The results from each group varied in their belief, although a common theme was to ensure that patients were educated about their disease.

Quantitative papers

Taylor et al (2012) looked at a pilot study concentrating on moderate-to-severe COPD patients and self-management. The intervention used was a lay person-led education programme, with the study looking at the feasibility of this approach in practice. The patients were randomised in a 2:1 intervention/control group, respectively.

There were 507 postal invites sent out to patients; however, 293 did not respond and 97 declined to take part. In total, 116 patients were recruited and randomised. The results of this study were recorded; however, no p value was given, the reason being that this is a pilot study. There was very little difference in the outcomes recorded in either intervention vs control group.

A second study looking at moderate-to-severe COPD was carried out by Bucknall et al (2012). The study aim was to see if supported self-management reduced readmissions to hospital. The study concluded that there was no effect on admission rate data for COPD through intervention.

A secondary end-point outcome found people who were less likely to follow up with the research scored lower in initial baseline scores for outcome measures. Overall, 61% of the study population were from the most socially deprived area within an inner city region of Scotland. Devereux (2006) stated that COPD prevalence is higher in socially deprived areas.

Jolly et al (2018) recruited 577 patients with mild COPD from 71 GP practices across England into an RCT, comparing telephone coaching to usual care for patients with COPD.

Similar studies have recruited from secondary care and have had a diagnosis of a more severe disease; however, Jolly et al (2018) wanted to conduct a primary care study. Other studies looked at longitudinal research having more benefit, as behavioural changes can take longer to be adapted into an individual’s lifestyle.

A multicentre RCT evaluating the hypothesis that individual action plans reduce exacerbation recovery time was conducted by Trappenburg et al (2011). Patients received usual care alongside an action plan (AP) and access to a case manager.

The results found that an action plan does not affect the exacerbation rate but does impact on recovery time. The p value showed no statistical difference. However, Miravitlles et al (2007) found that a patient perspective of quicker recovery was pertinent. Hence, this outcome was found to be clinically relevant to the participants. There was no increase in health professional contact in either group.

The last study to be appraised was performed over a 24-month period in the Netherlands. Bischoff et al (2012) led a multicentre three-arm investigator-blinded pragmatic RCT. The primary outcome (PO) was specific QOL, the secondary outcomes looked at self-efficacy, domain scores for QOL and frequency and patient management measurement with Nijmegen telephonic assessment system. The study found no difference in the PO for QOL; however, patients in the self-management group seemed more capable of appropriately managing exacerbations.

It has been highlighted by WHO (2020) that reliance on clinical codes for diagnostics needs to be more robust. In this study, it was found that, during baseline observations and inclusion, 60% of the patients identified were not relevant for study from practices as they were found to have an FEV1/FVC ratio >0.70, therefore, having no diagnosis of COPD.

Discussion

The aim of this critical appraisal was to assess the benefits of self-management plans for patients with COPD in the community setting. Preliminary research found relevant studies that were based in secondary care. However, only a small number of studies focused on the primary care setting. Overall, through critiquing and assessing the literature, no statistical evidence has been found that recognises many benefits to using self-management plans.

Descombe (2012) argued that a systematic approach is used when completing a literature search, demonstrating appropriate depth and breadth of reading. The quality of the literature search is crucial in the overall quality of the review.

Self-management plans are implemented as part of the NICE (2018) guidelines for the management of COPD. The guidelines suggest that individualised care plans must be completed in collaboration with patients and their family/carers to assist with proactive and supportive care delivery. Berns (2016) suggested that both patient- and professional-led management plans are used for chronic disease management, including asthma and diabetes. The authors further stated that, in adjunct to robust education and empowerment of individuals, these plans can be very effective.

Throughout this study, it was identified that there is substantial heterogeneity in self-management intervention criteria. This led to differences in the focus of some studies. The content of a self-management plan can be variable, reducing the efficacy of comparing data for analysis, highlighting the need for a future study to look at the content of self-management plans. Much of the research looks at self-management treatment with antibiotics and steroids, rather than a management plan in the broadest sense. Bucknall et al (2012) investigated if the use of symptom diaries with action plans could reduce hospital admission and mortality in COPD patients and concluded that no significant difference was found in this data. However, they also found that using generic self-management in isolation was unlikely to be beneficial without other intervention (Bucknall et al, 2012).

Patient perception

Only one study took into consideration patients’ views on self-management treatment. This was carried out by a qualitative, phenomenological approach, which was an appropriate study design. Having only one research paper focusing on the patient’s views can be considered an inadequate amount of research to give a more generalised view of the population and how other patients’ view self-management, in general. Unlike other studies, this article covered all severity of disease rather than one specific category. The five assessed RCTs had varying methods of self-management intervention in to determine the quality outcomes for using this method in practice, all set in the community, with differing severity of disease. The studies differed in length, ranging from 6 to 24 months. Taylor et al (2012) support the notion that self-management skills should be developed and nurtured over time. Murphey et al (2016), in their review of the literature, suggested that self-management plans are generally inexpensive to initiate and maintain, and that cost-effective benefits would be substantial, including reduction of hospital admission, personal cost to patient and overall financial burden to the NHS. However, Currie and Miller (2016) suggested that the cost-effective benefits would not apply if they were not used appropriately with other methods of support. In this sense, the implementation and delivery need to be reviewed regularly with ongoing evaluations and tailored to individuals. Due to the short length of the studies in this review, a failure to capture the long-term benefits of these plans would potentially limit the validity of the findings. Jonkman et al (2016) agreed and stated that there is evidence in their review that ongoing contact with patients may prevent attrition of treatment effects.

A recent systematic review was undertaken by Gardener et al (2016) focusing on the support needs of patients with COPD. A total of 11 studies identified patients’ need for support in managing their condition. A number of these primary studies reported that patients want a more dynamic support network, particularly when managing exacerbations. Partridge et al (2011) and Philip et al (2012) both eluded that patient perspective placed a value on guidance in care-in essence, when to take medications rather than making autonomous decisions and providing feedback to patients about effective self-management during an exacerbation. The range of data covered in this systematic review were mostly qualitative in nature.

Following a phenomenological design, this review has gained insights into patients’ lived experiences with COPD. The review has identified a comprehensive set of domains in which patients felt they needed support to manage their COPD, ranging from both health and social support. Self-management of disease was a key component. Reflecting on this recent study and how this emerging evidence can be implemented in practice using self-management plans tailored to patients, the identified needs would require further research.

What patients want

Self-management may be used better and improve outcomes if more qualitative research is implemented to find out what is important to patients and what they want. This outcome measure may provide more beneficial data for practice, rather than measuring quantitative outcomes in current practice. Disease severity-whether this be mild, moderate or severe-is a requirement during the recruitment of patients with a COPD diagnosis and for robust qualitative research. This lends itself to informing evidence-based practice and what meets the needs of the patient group (Murphy et al, 2016).

When appraising the research, it was highlighted that some interventions were: heterogeneous concerning content, severity of disease, method of delivery, duration of study and intensity of research intervention. However, an err on the side of caution is required when making comparisons between papers. It may be beneficial when working on a critical review to choose either qualitative or quantitative research, and not both. However, Wallace and Wray (2016) found it beneficial to gain insight into both statistical interpretation and personal interpretation of self-management plans and gave extra sustenance to the review.

One point highlighted in many of the studies was the improvement in patient’s knowledge and understanding of COPD, but, in line with Niknami et al (2018), Jolly et al (2018) found that improvement in knowledge of disease does not always lead to improvement in self-management skills.

Education is an important component in case management and self-management practice (Wang et al, 2017). In mild stable disease, it may be assumed that participation in self-management behaviours would be considerably easier to adopt and, as before, patients are typically faced with less morbidity-related complications. However, in the studies that target milder disease severity, this has not been proven. NICE (2018) acknowledge that education in practice is an essential criterion to engage people with self-management skills and behaviours.

Challenges to self-management

Seto et al (2017) noted that patients face numerous challenges when self-managing conditions, including complex decision-making about their care. The cost of healthcare is rising, so it is essential to enhance patient self-care and clinical management to reduce healthcare spending and improve patient outcomes. Panagioti et al (2014) agreed and stated a key driver for self-management is the potential to make significant contribution to healthcare delivery by increasing patient engagement. This raises the question about how patients are engaged in practice in their own care. Many of the appraised studies found that participation uptake is poor compared to the number of eligible candidates who were sent invites. In Bucknall et al’s (2012) study, only 53% of eligible candidates agreed to take part in the study. The level of education in primary care needs to be reviewed to evaluate if this uptake in research could be improved.

Building relationships is imperative in successful self-management. Several key themes were identified by Davies et al (2014), including cultural differences and beliefs of the professionals. The majority of the professionals in this study raised concerns over the level and understanding of the patients and how to manage an exacerbation without medical support. Both Davies et al (2014) and Laue et al (2017) have a common theme of trust in health professionals. Davies et al (2014) suggested developing trust, rapport and continuity to engage patients in the self-management of both disease and AECOPD. Arguably, Laue et al (2017) found patients often have a lack of trust in health professionals. However, Panagioti et al (2014) suggested that some self-management interventions may increase the demand on healthcare services.

Outcome measures

Several of the studies measured similar outcome questionnaires that included Health-Related Quality of Life (HRQoL), St. George’s Respiratory Questionnaire (SGRQ) and self-efficacy, to gauge if these improved with the intervention that was taking place. No statistical significance was found from baseline to end of follow-up in most of the studies; however, some clinical significance was identified in the study by Taylor et al (2017).

Hosseinzadeh and Shnaigat (2019) indicated that self-efficacy was not a major driver of self-managing behaviour and it enabled patients with COPD to deal with challenges. Bischoff et al (2012), Jolly et al (2014) and Taylor et al (2017) all found no difference in self-efficacy in both short- and long-term follow-ups. In a study by Guo et al (2017), it was implied that self-efficacy was essential in changing and maintaining the self-management behaviours inherent in management skills. When looking at patient’s readiness to follow self-management plans, self-efficacy is essential in improving the effectiveness of self-management interventions (Gardener et al, 2018).

In most of the studies, participant characteristics were similar in terms of recorded demographic details. Several studies ensured similar characteristics within the control and intervention group prior to randomisation to give a clearer, more concise and robust study (Bucknall et al, 2012; Davies et al 2014; Taylor et al 2017).

Strengths and limitations

A robust method of searching the available literature was carried out in the initial phases of this study to help answer the research question. This, in turn, led the author to look at a gap in practice and theoretical knowledge around the subject. Several studies looked at multiple chronic diseases with little exploration around COPD as a standalone topic. The search concepts may have been considered too narrow if, both community and benefits of using the plans were not included. The results without either of these concepts would have been too large to draw conclusions. Therefore, the choice was made to include both.

Several research methods were used in this critical review; however, only one paper considered patient views via interviewing/observation techniques. Glasper and Rees (2013) stated that consideration should be made when planning research development and design, using interview situations and FGD discussions, as it may improve participation and encourage meaningful discussion (Green and Thorogood, 2018). In a quantitative design, it is essential to ensure the right design method is used to answer the research question. Particular attention is given to the collection and sampling methods used, although there is variation in design. Bootland et al (2017) suggested that implementing new clinical practice is a hard task, but also an important one and can often transition from paper to patient if it is not performed well. They also suggested patients are key decision-makers in local policy. Analytical data from research needs to be non-biased and trustworthy to enable this drive forward in evidence-based medicine.

The critical appraisal did not follow an analytical framework; this was largely due to the papers being both qualitative and quantitative. The author preferred extracting data from the papers looking for key themes, rigour and their validity, and comparing it to the aim of the research, which is recorded in Table 1. This may be seen as an unstructured approach, but the author felt this was necessary for dual research methods.

This paper adds to previous studies that have already been completed regarding the efficacy of not only self-management plans, but also self-management interventions in general. Due to the heterogeneous nature of the studies so far, it may be of interest for a study to be completed looking at more specific details and the beliefs and needs of the patients, in terms of what it is they want in practice.

The findings from this article are linked to current practice and how self-management is understood and used by both patients and healthcare professionals. The drive for more qualitative literature ultimately seeks experienced researchers to develop skills in adapting research design to meet the needs of the population with COPD patients.

Conclusion

Throughout this paper, several key themes have been identified when dealing with self-management in COPD. Self-management plans have a place in current practice to empower individuals to manage their own condition. Although national guidelines highlight the importance of self-management plans, there is no set structure to these plans or what they contain.

As it stands, benefits of self-management plans are minimal, concerning outcome measures for QOL, self-efficacy and hospital admission data. However, some patients had a greater knowledge and understanding of their disease through the trials they were involved in.

Patient education and establishing supportive relationships with health professionals has been highlighted as a key component in the efficacy of self-management for COPD patients in varying stages of the disease. Embedding self-management plans into educative packages and empowering individuals with knowledge and self-belief may improve patient outcomes, rather than using self-management plans as standalone practice. Further exploration of patient and professional perceptions would be of benefit in future research projects.

Key Points

• Self-Management plans are recommended in national guidance as part of COPD management in the community.
• There is no specific definition of what self-management entails including what content a plan should consider
• More research is required to encompass patient perception of management of long-term conditions including COPD management

CPD reflective questions

• Do you use self-management plans in practice and when are they implemented?
• What content do you want within a self-management plan?
• How would you explore with patients, carers or family members, their perspective on using self-management plans and would you include any statistical data?