BACKGROUND: Self-management interventions help people with chronic obstructive pulmonary disease (COPD) to acquire and practise the skills they need to carry out disease-specific medical regimens, guide changes in health behaviour and provide emotional support to enable them to control their disease. Since the 2014 update of this review, several studies have been published.
OBJECTIVES: Primary objectives To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of health-related quality of life (HRQoL) and respiratory-related hospital admissions. To evaluate the safety of COPD self-management interventions compared to usual care in terms of respiratory-related mortality and all-cause mortality. Secondary objectives To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of other health outcomes and healthcare utilisation. To evaluate effective characteristics of COPD self-management interventions.
SEARCH METHODS: We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, EMBASE, trials registries and the reference lists of included studies up until January 2020.
SELECTION CRITERIA: Randomised controlled trials (RCTs) and cluster-randomised trials (CRTs) published since 1995. To be eligible for inclusion, self-management interventions had to include at least two intervention components and include an iterative process between participant and healthcare provider(s) in which goals were formulated and feedback was given on self-management actions by the participant.
DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, assessed trial quality and extracted data. We resolved disagreements by reaching consensus or by involving a third review author. We contacted study authors to obtain additional information and missing outcome data where possible. Primary outcomes were health-related quality of life (HRQoL), number of respiratory-related hospital admissions, respiratory-related mortality, and all-cause mortality. When appropriate, we pooled study results using random-effects modelling meta-analyses.
MAIN RESULTS: We included 27 studies involving 6008 participants with COPD. The follow-up time ranged from two-and-a-half to 24 months and the content of the interventions was diverse. Participants' mean age ranged from 57 to 74 years, and the proportion of male participants ranged from 33% to 98%. The post-bronchodilator forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) ratio of participants ranged from 33.6% to 57.0%. The FEV1/FVC ratio is a measure used to diagnose COPD and to determine the severity of the disease. Studies were conducted on four different continents (Europe (n = 15), North America (n = 8), Asia (n = 1), and Oceania (n = 4); with one study conducted in both Europe and Oceania). Self-management interventions likely improve HRQoL, as measured by the St. George's Respiratory Questionnaire (SGRQ) total score (lower score represents better HRQoL) with a mean difference (MD) from usual care of -2.86 points (95% confidence interval (CI) -4.87 to -0.85; 14 studies, 2778 participants; low-quality evidence). The pooled MD of -2.86 did not reach the SGRQ minimal clinically important difference (MCID) of four points. Self-management intervention participants were also at a slightly lower risk for at least one respiratory-related hospital admission (odds ratio (OR) 0.75, 95% CI 0.57 to 0.98; 15 studies, 3263 participants; very low-quality evidence). The number needed to treat to prevent one respiratory-related hospital admission over a mean of 9.75 months' follow-up was 15 (95% CI 8 to 399) for participants with high baseline risk and 26 (95% CI 15 to 677) for participants with low baseline risk. No differences were observed in respiratory-related mortality (risk difference (RD) 0.01, 95% CI -0.02 to 0.04; 8 studies, 1572 participants ; low-quality evidence) and all-cause mortality (RD -0.01, 95% CI -0.03 to 0.01; 24 studies, 5719 participants; low-quality evidence). We graded the evidence to be of 'moderate' to 'very low' quality according to GRADE. All studies had a substantial risk of bias, because of lack of blinding of participants and personnel to the interventions, which is inherently impossible in a self-management intervention. In addition, risk of bias was noticeably increased because of insufficient information regarding a) non-protocol interventions, and b) analyses to estimate the effect of adhering to interventions. Consequently, the highest GRADE evidence score that could be obtained by studies was 'moderate'.
AUTHORS' CONCLUSIONS: Self-management interventions for people with COPD are associated with improvements in HRQoL, as measured with the SGRQ, and a lower probability of respiratory-related hospital admissions. No excess respiratory-related and all-cause mortality risks were observed, which strengthens the view that COPD self-management interventions are unlikely to cause harm. By using stricter inclusion criteria, we decreased heterogeneity in studies, but also reduced the number of included studies and therefore our capacity to conduct subgroup analyses. Data were therefore still insufficient to reach clear conclusions about effective (intervention) characteristics of COPD self-management interventions. As tailoring of COPD self-management interventions to individuals is desirable, heterogeneity is and will likely remain present in self-management interventions. For future studies, we would urge using only COPD self-management interventions that include iterative interactions between participants and healthcare professionals who are competent using behavioural change techniques (BCTs) to elicit participants' motivation, confidence and competence to positively adapt their health behaviour(s) and develop skills to better manage their disease. In addition, to inform further subgroup and meta-regression analyses and to provide stronger conclusions regarding effective COPD self-management interventions, there is a need for more homogeneity in outcome measures. More attention should be paid to behavioural outcome measures and to providing more detailed, uniform and transparently reported data on self-management intervention components and BCTs. Assessment of outcomes over the long term is also recommended to capture changes in people's behaviour. Finally, information regarding non-protocol interventions as well as analyses to estimate the effect of adhering to interventions should be included to increase the quality of evidence.
JUSTIFICATIVA Y OBJETIVO: La enfermedad pulmonar obstructiva crónica está aumentando en la prevalencia y constituye una de las principales causas de morbilidad y mortalidad a nivel mundial. Además de contribuir a una disminución significativa del estado de salud en muchos pacientes, esta condición crea una carga considerable para los proveedores de atención médica. Las intervenciones de autogestión se implementan frecuentemente en entornos comunitarios para limitar el impacto de la enfermedad pulmonar obstructiva crónica en la vida cotidiana de los individuos y para controlar la presión sobre los sistemas de salud. Las enfermeras son el grupo profesional más probable para proporcionar apoyo de auto-gestión. Esta revisión sistemática tiene como objetivo evaluar la clínica y la rentabilidad de la enfermería de auto-gestión dirigida a pacientes con enfermedad pulmonar obstructiva crónica en atención primaria. FUENTES DE DATOS: Siete bases de datos electrónicas, incluyendo el Índice de Enfermería Británico, MEDLINE, CINAHL, AMED, EMBASE, la Biblioteca Cochrane y la Base de Datos de Evaluación Económica del NHS , Se buscaron estudios relevantes. MÉTODOS DE REVISIÓN: Se utilizó la lista de verificación de los Informes Preferidos para Revisiones Sistemáticas y Meta-Análisis para guiar la estructura de la revisión. La relevancia de las citas se evaluó sobre la base de criterios de inclusión, con los textos completos recuperados como se requiere para llegar a una decisión. Dos revisores extrajeron los datos de forma independiente. Se utilizó la herramienta Cochrane de riesgo de sesgo para realizar una revisión de calidad. Se utilizó un método de resumen narrativo para describir los resultados de la revisión. RESULTADOS: En el análisis se incluyeron veintiséis artículos que describían 20 ensayos controlados aleatorios. Las intervenciones de autogestión fueron heterogéneas, con un número variable de componentes, nivel de apoyo, modo de administración y duración del seguimiento. La revisión demostró que los programas de autocontrol dirigidos por enfermeras pueden estar asociados con reducciones en la ansiedad y visitas no programadas del médico y aumentos en la autoeficacia, pero no se pudieron llegar a conclusiones definitivas. Pocos estudios abordaron resultados económicos y las diversas perspectivas, marcos de tiempo y escenarios dificultaron las comparaciones. La evidencia sobre costo-efectividad no fue concluyente. Algunos programas de autocontrol dirigidos por enfermeras en esta revisión sistemática produjeron efectos beneficiosos en términos de reducir las visitas no programadas del médico, disminuir la ansiedad de los pacientes y aumentar la autoeficacia, pero no hay evidencia suficiente para llegar a conclusiones firmes sobre el costo clínico o costo- Eficacia de las intervenciones. Las investigaciones posteriores deben tener como objetivo identificar los componentes óptimos de estos programas e identificar a los pacientes con más probabilidades de beneficiarse. La inclusión de análisis económicos en futuros estudios facilitaría las decisiones de los responsables de la formulación de políticas sobre la aplicación de las intervenciones de autogestión.
OBJETIVO: En Australia, muchos investigadores de la salud y responsables políticos están abogando por las etiquetas de advertencia por mandato sobre las bebidas alcohólicas. Daños relacionados con el alcohol son motivo de especial preocupación entre los adolescentes. El objetivo de este artículo es revisar la bibliografía disponible y evaluar el impacto de las advertencias sobre el consumo de alcohol adolescente, el conocimiento y el comportamiento.
ENFOQUE: Se realizó una revisión sistemática de la literatura. Se realizaron búsquedas en bases de datos académicas para los artículos de investigación relevantes. Criterios amplios de inclusión se aplicaron debido a la relativa escasez de literatura.
CONCLUSIÓN: La introducción de las etiquetas de advertencia de alcohol ha demostrado estar asociada con una mayor conciencia inicial de alcohol ley advertencia en la etiqueta, la exposición a las etiquetas, y un mayor reconocimiento de los mensajes de la etiqueta de advertencia. Por el contrario, se observó poco cambio en cuanto a las creencias sobre los riesgos del consumo de alcohol o la participación en las conductas de riesgo relacionadas con el alcohol. Estos hallazgos son similares a los reportados entre muestras de adultos. Sin embargo, la gran mayoría de la literatura se originó a partir del mismo grupo de autores, con muestras extraídas de una misma región geográfica. Esto puede limitar en gran medida la generalisablity de estos hallazgos.
CONSECUENCIAS: La introducción de las etiquetas de advertencia de alcohol en Australia pueden aumentar la sensibilización sobre los riesgos del consumo de alcohol entre los adolescentes, sin embargo, parece poco probable que cambien los comportamientos potable adolescentes o creencias sobre los riesgos relacionados con el alcohol estas etiquetas. Se necesita más investigación en múltiples contextos culturales para confirmar estos hallazgos. Etiquetas de advertencia de alcohol deben considerarse como sólo un aspecto de una serie de otras estrategias comprobadas para modificar sus conocimientos, actitudes y comportamientos.
OBJETIVO: Revisar la evidencia publicada sobre la rentabilidad de los programas EPOC multicomponentes y para ilustrar cómo potencialmente cuestan programas eficaces pueden ser identificados.
Métodos: Búsqueda sistemática de las bases de datos Medline y Cochrane para las evaluaciones de la gestión de la enfermedad de múltiples componentes o programas de atención crónica en adultos con EPOC, proceso que describen, intermedios, y los resultados finales de la atención. Los datos fueron extraídos de forma independiente por dos revisores y descriptivamente resumidos.
RESULTADOS: Veinte artículos que describen 17 programas únicos EPOC fueron incluidos. Hay poca evidencia de mejoras significativas en los procesos y resultados intermedios, a excepción de una mayor provisión de educación para el autocuidado del paciente y mejorar el conocimiento específico de la enfermedad. En general, los programas de EPOC generan resultados finales equivalentes a la atención habitual, pero los programas que contiene> o = 3 componentes muestran los riesgos relativos más bajos de hospitalización. Hay pocas posibilidades de programas al punto de equilibrio o ahorrar dinero.
CONCLUSIÓN: La identificación de programas con EPOC de varios componentes de costo efectivo sigue siendo un desafío debido a la escasez de estudios metodológicamente sólidos que demuestran una mejora significativa sobre el proceso, los resultados intermedios y finales de la atención. Las estimaciones del potencial de rentabilidad de los programas específicos ilustran en este documento puede, en ausencia de «datos perfectos ', apoyar la oportuna toma de decisiones con respecto a estos programas. Sin embargo, se necesitan estudios bien diseñados economía de la salud para reducir la incertidumbre en la toma de corriente.
ANTECEDENTES: La efectividad de las intervenciones múltiples en el asma y enfermedad pulmonar obstructiva crónica (EPOC) es poco clara.
OBJETIVO: Analizar la efectividad de las intervenciones múltiples en comparación con las intervenciones individuales o la atención habitual en los resultados sanitarios y la utilización de atención de la salud en el contexto del manejo integrado de enfermedades en el asma y la EPOC.
MÉTODOS: MEDLINE y la Cochrane Library (1995-mayo de 2008) Se realizaron búsquedas de ensayos controlados. Dos revisores extrajeron los datos y evaluaron la calidad del estudio. Meta-análisis se realizaron sobre la calidad de vida y los datos de salud de utilización. Por otra parte, los efectos de las intervenciones múltiples en comparación con las intervenciones individuales y el cuidado general fueron evaluados cualitativamente.
RESULTADOS: De los 36 estudios incluidos, 17 intervenciones específicas dobles (relacionada con el paciente y las intervenciones de la organización); 19 estudios llevados a cabo intervenciones de triples (relacionados con los pacientes, profesionales y organizativas dirigidas las intervenciones). Ellos fueron heterogéneos en términos de (combinaciones de) las intervenciones, el diseño de estudio de los resultados medidos, y el ambiente. Los datos combinados mostraron que estudiaron los programas de manejo de la enfermedad mejoró significativamente la calidad de vida en varios dominios. Los pacientes dentro de los programas de intervención triples tenían menos posibilidades de ingreso en el hospital al menos una comparación con la atención habitual. No se encontraron efectos significativos en el número de visitas a urgencias. El análisis cualitativo reveló tendencias positivas en la mejora de los procesos y la satisfacción. Los resultados no concluyentes se informó sobre los síntomas, no se encontraron efectos en la función pulmonar.
CONCLUSIÓN: A pesar de la heterogeneidad de los estudios de manejo de enfermedades en el tratamiento del asma y la EPOC, esta revisión mostró mejoras prometedoras en la calidad de vida y la reducción de las hospitalizaciones, especialmente para los programas de intervención triples.
Self-management interventions help people with chronic obstructive pulmonary disease (COPD) to acquire and practise the skills they need to carry out disease-specific medical regimens, guide changes in health behaviour and provide emotional support to enable them to control their disease. Since the 2014 update of this review, several studies have been published.
OBJECTIVES:
Primary objectives To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of health-related quality of life (HRQoL) and respiratory-related hospital admissions. To evaluate the safety of COPD self-management interventions compared to usual care in terms of respiratory-related mortality and all-cause mortality. Secondary objectives To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of other health outcomes and healthcare utilisation. To evaluate effective characteristics of COPD self-management interventions.
SEARCH METHODS:
We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, EMBASE, trials registries and the reference lists of included studies up until January 2020.
SELECTION CRITERIA:
Randomised controlled trials (RCTs) and cluster-randomised trials (CRTs) published since 1995. To be eligible for inclusion, self-management interventions had to include at least two intervention components and include an iterative process between participant and healthcare provider(s) in which goals were formulated and feedback was given on self-management actions by the participant.
DATA COLLECTION AND ANALYSIS:
Two review authors independently selected studies for inclusion, assessed trial quality and extracted data. We resolved disagreements by reaching consensus or by involving a third review author. We contacted study authors to obtain additional information and missing outcome data where possible. Primary outcomes were health-related quality of life (HRQoL), number of respiratory-related hospital admissions, respiratory-related mortality, and all-cause mortality. When appropriate, we pooled study results using random-effects modelling meta-analyses.
MAIN RESULTS:
We included 27 studies involving 6008 participants with COPD. The follow-up time ranged from two-and-a-half to 24 months and the content of the interventions was diverse. Participants' mean age ranged from 57 to 74 years, and the proportion of male participants ranged from 33% to 98%. The post-bronchodilator forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) ratio of participants ranged from 33.6% to 57.0%. The FEV1/FVC ratio is a measure used to diagnose COPD and to determine the severity of the disease. Studies were conducted on four different continents (Europe (n = 15), North America (n = 8), Asia (n = 1), and Oceania (n = 4); with one study conducted in both Europe and Oceania). Self-management interventions likely improve HRQoL, as measured by the St. George's Respiratory Questionnaire (SGRQ) total score (lower score represents better HRQoL) with a mean difference (MD) from usual care of -2.86 points (95% confidence interval (CI) -4.87 to -0.85; 14 studies, 2778 participants; low-quality evidence). The pooled MD of -2.86 did not reach the SGRQ minimal clinically important difference (MCID) of four points. Self-management intervention participants were also at a slightly lower risk for at least one respiratory-related hospital admission (odds ratio (OR) 0.75, 95% CI 0.57 to 0.98; 15 studies, 3263 participants; very low-quality evidence). The number needed to treat to prevent one respiratory-related hospital admission over a mean of 9.75 months' follow-up was 15 (95% CI 8 to 399) for participants with high baseline risk and 26 (95% CI 15 to 677) for participants with low baseline risk. No differences were observed in respiratory-related mortality (risk difference (RD) 0.01, 95% CI -0.02 to 0.04; 8 studies, 1572 participants ; low-quality evidence) and all-cause mortality (RD -0.01, 95% CI -0.03 to 0.01; 24 studies, 5719 participants; low-quality evidence). We graded the evidence to be of 'moderate' to 'very low' quality according to GRADE. All studies had a substantial risk of bias, because of lack of blinding of participants and personnel to the interventions, which is inherently impossible in a self-management intervention. In addition, risk of bias was noticeably increased because of insufficient information regarding a) non-protocol interventions, and b) analyses to estimate the effect of adhering to interventions. Consequently, the highest GRADE evidence score that could be obtained by studies was 'moderate'.
AUTHORS' CONCLUSIONS:
Self-management interventions for people with COPD are associated with improvements in HRQoL, as measured with the SGRQ, and a lower probability of respiratory-related hospital admissions. No excess respiratory-related and all-cause mortality risks were observed, which strengthens the view that COPD self-management interventions are unlikely to cause harm. By using stricter inclusion criteria, we decreased heterogeneity in studies, but also reduced the number of included studies and therefore our capacity to conduct subgroup analyses. Data were therefore still insufficient to reach clear conclusions about effective (intervention) characteristics of COPD self-management interventions. As tailoring of COPD self-management interventions to individuals is desirable, heterogeneity is and will likely remain present in self-management interventions. For future studies, we would urge using only COPD self-management interventions that include iterative interactions between participants and healthcare professionals who are competent using behavioural change techniques (BCTs) to elicit participants' motivation, confidence and competence to positively adapt their health behaviour(s) and develop skills to better manage their disease. In addition, to inform further subgroup and meta-regression analyses and to provide stronger conclusions regarding effective COPD self-management interventions, there is a need for more homogeneity in outcome measures. More attention should be paid to behavioural outcome measures and to providing more detailed, uniform and transparently reported data on self-management intervention components and BCTs. Assessment of outcomes over the long term is also recommended to capture changes in people's behaviour. Finally, information regarding non-protocol interventions as well as analyses to estimate the effect of adhering to interventions should be included to increase the quality of evidence.
