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EDITORIAL
Education in COPD self-management: only part of the game Key words: chronic obstructive pulmonary disease, education, exercise, pulmonary rehabilitation, self-management.
Self-management programmes can be defined as programmes to help patients acquire and practice the skills they need to carry out disease-specific medical regimens, to guide change in health behaviour, and to provide emotional support in order to enable patients to adjust their roles for optimal function and control of their disease.1,2 The term ‘self-management education’ suggests a limitation to transferring knowledge only, which will most of the times not lead to behavioural change. When talking about interventions to improve patients’ capacity to self-manage, education about self-management is only part of the game.1 Self-management is an aspect of the continuum of disease management in which disease management by the patient is always accompanied by disease management by health-care providers.1 In selfmanagement, goal setting is important, as are problem solving, decision-making and taking action.3 To fulfil set goals, a knowledge component is required, and this will usually require an education component. In addition, of utmost importance are providing appropriate tools, training the necessary skills and the possibility to incorporate the approach in existing health-care support systems.1 If, for example the intervention is directed towards the use of action plans for chronic obstructive pulmonary disease exacerbations, symptom-monitoring aids and action plans (tools) need to be provided. Subsequently, patients need to be trained in using these tools, and this will require at least an iterative process of interaction between patient and health-care provider and ideally also includes formulation of (sub)goals and providing feedback (developing skills). Finally, the approach needs to be incorporable into the existing health-care structure, for example the involvement of a physician and a case-manager. If the tools, skills and health-care structure are accounted for, patients still need to apply the trained skills and use the tools on a regular basis. To facilitate the latter, various behavioural change techniques can be included in interventions (e.g. motivational interviewing and the use of cognitive behavioural therapy techniques4,5). If appropriate tools, skills, health-care structures or behavioural change are lacking, effects of self-management interventions can expected to be suboptimal or absent. In the study of Blackstock et al.,6 the addition of education and the use of individual behaviouralspecific action plans to a rehabilitation programme did not lead to any additional effects. In this study, 16 45-minute educational sessions were delivered. Besides discussing a wide variety of topics, individual © 2013 The Authors Respirology © 2013 Asian Pacific Society of Respirology
behaviour-specific action plans were formulated and reviewed in each group session. These action plans involved participants making a short-term plan to change specific aspects of their lifestyle over a 1–2week period. It is highly likely that this approach has led to a wide variety of intended lifestyle changes (e.g. increase activity levels, stop smoking, self-treatment of exacerbations). In aiming for different lifestyle changes, multiple sets of different tools, skills and health-care structures should have been in place. A lack of detailed intervention description makes it hard to determine whether all intervention requirements were in place and what outcomes, as a result, could be expected. It should be acknowledged that a possible barrier for including this detailed information in the body of the manuscript is the limit on word count required by journals. However, the use of online repositories, as is offered by Respirology, removes this barrier. Patient-tailored programmes might be preferable to pre-defined rigid programmes because an a priori defined set of goals is often not personally attractive for patients and this might contribute to nonadherence.4 However, evaluation of patient-tailored programmes can be problematic in a randomized controlled trial design. Patient-tailored programmes will lead to different treatment goals, different interventions and thus different targeted outcomes between patients. Large patient populations will be necessary to have sufficient numbers for each targeted outcome. Whereas Blackstock et al.6 included a relatively large group of patients, individualising the intervention might have reduced the power of their study. However, the lack of any difference between groups indicates that the use of this education component and these action plans have not led to any additional effects compared to pulmonary rehabilitation alone. An intervention that includes all of the necessary elements can still be ineffective if not delivered in the pre-defined way.7 Training of the health-care providers who deliver the intervention is therefore essential, and an evaluation of the way the intervention is actually delivered is highly desirable. In the Blackstock study,6 the health-care providers had experience in conducting pulmonary rehabilitation and were likely encouraging ongoing exercise maintenance, but nothing was stated regarding specific training of health-care providers in self-management in general and behavioural change techniques in particular. Also, no process evaluation was performed. This implies that when all necessary elements were included in the intervention, the delivery of the intervention could still have been suboptimal. Respirology (2014) 19, 151–152 doi: 10.1111/resp.12231
152 Apart from the discussion of whether or not the intervention was designed to target changes in quality of life and delivered according to protocol, we need to question what could realistically be expected from adding a proven effective self-management intervention to an intense exercise programme. Evidence shows that pulmonary exercise programmes lead to significant and clinically relevant changes in quality of life.8,9 Self-management interventions have also proven to result in quality-of-life changes, but these changes are smaller and do not always reach clinical relevance.10 It is therefore questionable whether we could, on an a priori basis, have expected any additional improvement in quality of life. If we were interested in maintenance of benefit, this would only be expected if techniques that target sustained behavioural change are included in the intervention.8 Additional benefits of self-management to those of pulmonary rehabilitation can realistically only be expected if interventions are specifically designed to target the outcomes of interest and the intervention is delivered according to protocol. The results of the Blackstock study6 indicate that adding education aimed at encouraging self-management to a wellconducted pulmonary exercise program is insufficient to further affect quality of life, exercise capacity and health-care in the short and long term. Hence, whether the addition of a proper patient-tailored selfmanagement intervention to pulmonary exercise will lead to additional benefits in the short and especially the long term remains unknown. Tanja Effing PhD,1,2 Job van der Palen PhD3,4 and Peter Frith MD1,2 1 Respiratory Research Unit, Repatriation General Hospital, 2School of Medicine, Flinders University, Adelaide, South Australia, Australia, 3Department of Research Methodology, Measurement and Data Analysis, University of Twente, and 4Department of Pulmonary Medicine, Medical Spectrum Twente, Enschede, The Netherlands
Respirology (2014) 19, 151–152
Editorial
REFERENCES 1 Effing TW, Bourbeau J, Vercoulen J, Apter AJ, Coultas D, Meek P, van der Valk P, Partridge MR, van der Palen J. Self-management programmes for COPD: moving forward. Chron Respir. Dis. 2012; 9: 27–35. 2 Bourbeau J, van der Palen J. Promoting effective selfmanagement programmes to improve COPD. Eur. Respir. J. 2009; 33: 461–3. 3 Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann. Behav. Med. 2003; 26: 1–7. 4 Vercoulen JH. A simple method to enable patient-tailored treatment and to motivate the patient to change behaviour. Chron Respir. Dis. 2012; 9: 259–68. 5 Fritzsche A, Clamor A, von Leupoldt A. Effects of medical and psychological treatment of depression in patients with COPD–a review. Respir. Med. 2011; 105: 1422–33. 6 Blackstock K, Webster K, McDonald C, Hill CS. Comparable improvements achieved in chronic obstructive pulmonary disease through pulmonary rehabilitation with and without a structured educational intervention: a randomized controlled trial. Respirology 2014; 2: 193–202. 7 Hardeman W, Michie S, Fanshawe T, Prevost T, McLoughlin K, Kinmonth L. Fidelity of delivery of a physical activity intervention: predictors and consequences. Psychol. Health 2008; 23: 11–24. 8 Spruit MA, Singh SJ, Garvey C, Zuwallack R, Nici L, Rochester C et al. An official american thoracic society/european respiratory society statement: key concepts and advances in pulmonary rehabilitation. Am. J. Respir. Crit. Care Med. 2013; 188: e13–64. 9 Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst. Rev. 2006; (4): CD003793. 10 Effing T, Monninkhof EM, van der Valk PD, van der Palen J, van Herwaarden CL, Partridge MR, Walters EH, Zielhuis GA. Selfmanagement education for patients with chronic obstructive pulmonary disease. Cochrane Database Syst. Rev. 2007; (4): CD002990.
© 2013 The Authors Respirology © 2013 Asian Pacific Society of Respirology
EDITORIAL
Education in COPD self-management: only part of the game Key words: chronic obstructive pulmonary disease, education, exercise, pulmonary rehabilitation, self-management.
Self-management programmes can be defined as programmes to help patients acquire and practice the skills they need to carry out disease-specific medical regimens, to guide change in health behaviour, and to provide emotional support in order to enable patients to adjust their roles for optimal function and control of their disease.1,2 The term ‘self-management education’ suggests a limitation to transferring knowledge only, which will most of the times not lead to behavioural change. When talking about interventions to improve patients’ capacity to self-manage, education about self-management is only part of the game.1 Self-management is an aspect of the continuum of disease management in which disease management by the patient is always accompanied by disease management by health-care providers.1 In selfmanagement, goal setting is important, as are problem solving, decision-making and taking action.3 To fulfil set goals, a knowledge component is required, and this will usually require an education component. In addition, of utmost importance are providing appropriate tools, training the necessary skills and the possibility to incorporate the approach in existing health-care support systems.1 If, for example the intervention is directed towards the use of action plans for chronic obstructive pulmonary disease exacerbations, symptom-monitoring aids and action plans (tools) need to be provided. Subsequently, patients need to be trained in using these tools, and this will require at least an iterative process of interaction between patient and health-care provider and ideally also includes formulation of (sub)goals and providing feedback (developing skills). Finally, the approach needs to be incorporable into the existing health-care structure, for example the involvement of a physician and a case-manager. If the tools, skills and health-care structure are accounted for, patients still need to apply the trained skills and use the tools on a regular basis. To facilitate the latter, various behavioural change techniques can be included in interventions (e.g. motivational interviewing and the use of cognitive behavioural therapy techniques4,5). If appropriate tools, skills, health-care structures or behavioural change are lacking, effects of self-management interventions can expected to be suboptimal or absent. In the study of Blackstock et al.,6 the addition of education and the use of individual behaviouralspecific action plans to a rehabilitation programme did not lead to any additional effects. In this study, 16 45-minute educational sessions were delivered. Besides discussing a wide variety of topics, individual © 2013 The Authors Respirology © 2013 Asian Pacific Society of Respirology
behaviour-specific action plans were formulated and reviewed in each group session. These action plans involved participants making a short-term plan to change specific aspects of their lifestyle over a 1–2week period. It is highly likely that this approach has led to a wide variety of intended lifestyle changes (e.g. increase activity levels, stop smoking, self-treatment of exacerbations). In aiming for different lifestyle changes, multiple sets of different tools, skills and health-care structures should have been in place. A lack of detailed intervention description makes it hard to determine whether all intervention requirements were in place and what outcomes, as a result, could be expected. It should be acknowledged that a possible barrier for including this detailed information in the body of the manuscript is the limit on word count required by journals. However, the use of online repositories, as is offered by Respirology, removes this barrier. Patient-tailored programmes might be preferable to pre-defined rigid programmes because an a priori defined set of goals is often not personally attractive for patients and this might contribute to nonadherence.4 However, evaluation of patient-tailored programmes can be problematic in a randomized controlled trial design. Patient-tailored programmes will lead to different treatment goals, different interventions and thus different targeted outcomes between patients. Large patient populations will be necessary to have sufficient numbers for each targeted outcome. Whereas Blackstock et al.6 included a relatively large group of patients, individualising the intervention might have reduced the power of their study. However, the lack of any difference between groups indicates that the use of this education component and these action plans have not led to any additional effects compared to pulmonary rehabilitation alone. An intervention that includes all of the necessary elements can still be ineffective if not delivered in the pre-defined way.7 Training of the health-care providers who deliver the intervention is therefore essential, and an evaluation of the way the intervention is actually delivered is highly desirable. In the Blackstock study,6 the health-care providers had experience in conducting pulmonary rehabilitation and were likely encouraging ongoing exercise maintenance, but nothing was stated regarding specific training of health-care providers in self-management in general and behavioural change techniques in particular. Also, no process evaluation was performed. This implies that when all necessary elements were included in the intervention, the delivery of the intervention could still have been suboptimal. Respirology (2014) 19, 151–152 doi: 10.1111/resp.12231
152 Apart from the discussion of whether or not the intervention was designed to target changes in quality of life and delivered according to protocol, we need to question what could realistically be expected from adding a proven effective self-management intervention to an intense exercise programme. Evidence shows that pulmonary exercise programmes lead to significant and clinically relevant changes in quality of life.8,9 Self-management interventions have also proven to result in quality-of-life changes, but these changes are smaller and do not always reach clinical relevance.10 It is therefore questionable whether we could, on an a priori basis, have expected any additional improvement in quality of life. If we were interested in maintenance of benefit, this would only be expected if techniques that target sustained behavioural change are included in the intervention.8 Additional benefits of self-management to those of pulmonary rehabilitation can realistically only be expected if interventions are specifically designed to target the outcomes of interest and the intervention is delivered according to protocol. The results of the Blackstock study6 indicate that adding education aimed at encouraging self-management to a wellconducted pulmonary exercise program is insufficient to further affect quality of life, exercise capacity and health-care in the short and long term. Hence, whether the addition of a proper patient-tailored selfmanagement intervention to pulmonary exercise will lead to additional benefits in the short and especially the long term remains unknown. Tanja Effing PhD,1,2 Job van der Palen PhD3,4 and Peter Frith MD1,2 1 Respiratory Research Unit, Repatriation General Hospital, 2School of Medicine, Flinders University, Adelaide, South Australia, Australia, 3Department of Research Methodology, Measurement and Data Analysis, University of Twente, and 4Department of Pulmonary Medicine, Medical Spectrum Twente, Enschede, The Netherlands
Respirology (2014) 19, 151–152
Editorial
REFERENCES 1 Effing TW, Bourbeau J, Vercoulen J, Apter AJ, Coultas D, Meek P, van der Valk P, Partridge MR, van der Palen J. Self-management programmes for COPD: moving forward. Chron Respir. Dis. 2012; 9: 27–35. 2 Bourbeau J, van der Palen J. Promoting effective selfmanagement programmes to improve COPD. Eur. Respir. J. 2009; 33: 461–3. 3 Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann. Behav. Med. 2003; 26: 1–7. 4 Vercoulen JH. A simple method to enable patient-tailored treatment and to motivate the patient to change behaviour. Chron Respir. Dis. 2012; 9: 259–68. 5 Fritzsche A, Clamor A, von Leupoldt A. Effects of medical and psychological treatment of depression in patients with COPD–a review. Respir. Med. 2011; 105: 1422–33. 6 Blackstock K, Webster K, McDonald C, Hill CS. Comparable improvements achieved in chronic obstructive pulmonary disease through pulmonary rehabilitation with and without a structured educational intervention: a randomized controlled trial. Respirology 2014; 2: 193–202. 7 Hardeman W, Michie S, Fanshawe T, Prevost T, McLoughlin K, Kinmonth L. Fidelity of delivery of a physical activity intervention: predictors and consequences. Psychol. Health 2008; 23: 11–24. 8 Spruit MA, Singh SJ, Garvey C, Zuwallack R, Nici L, Rochester C et al. An official american thoracic society/european respiratory society statement: key concepts and advances in pulmonary rehabilitation. Am. J. Respir. Crit. Care Med. 2013; 188: e13–64. 9 Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst. Rev. 2006; (4): CD003793. 10 Effing T, Monninkhof EM, van der Valk PD, van der Palen J, van Herwaarden CL, Partridge MR, Walters EH, Zielhuis GA. Selfmanagement education for patients with chronic obstructive pulmonary disease. Cochrane Database Syst. Rev. 2007; (4): CD002990.
© 2013 The Authors Respirology © 2013 Asian Pacific Society of Respirology
