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Exclusive Cochrane summary

Using action plans for COPD patients

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Education about COPD may improve patients’ knowledge about self-management. This Cochrane review compared action plans with standard interventions

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Carlson G (2011) Using action plans for COPD patients. Nursing Times; 107: 15/16, early online publication.

Review questions

What is the efficacy of action plans in the management of chronic obstructive pulmonary disease (COPD)? Does the use of action plans help patients recognise worsening of COPD symptoms and trigger early treatment, so decreasing the severity of exacerbation?

Nursing implications

Nurses play an important role in the management of COPD.

Using action plans for COPD patients may improve their knowledge about self-management and intentions to follow appropriate actions for exacerbations.

This review aimed to find out how effective these action plans were.

Study characteristics

The review included five parallel group randomised controlled trials, with a total of 574 participants with COPD.

Participants had primary COPD diagnosed by a health practitioner using spirometric criteria (spirometry measures the air capacity of the lung), and who had a history of smoking. Studies involving participants who had a primary diagnosis of asthma were excluded unless results were available separately for those who also had COPD.

The intervention was the use of an action plan. This was described as the use of guidelines detailing self-initiated interventions, such as changing the medication regimen or visiting a GP or hospital. These interventions were done in response to alterations in the state of participants’ COPD, for example increased breathlessness or an increase in the amount or purulence of sputum – the kind of changes that would suggest the start of an exacerbation.

An educational component was allowed, provided that it was less than one hour in length.

There were some differences in the interventions used by participants but they all had the following elements: early recognition of exacerbation; self-initiated interventions; and advice on when to seek medical care. The intervention group was compared with “usual care”. Usual care varied between studies, but all these participants did not have access to the action plan. Follow-up was carried over a period of six to 12 months.

The primary outcomes measured were participants’ healthcare usage and their use of medications. Secondary outcomes measured were health-related quality of life, COPD management knowledge and actions, acute exacerbations, mortality, psychological morbidity, lung function, functional capacity, symptom scores and days lost from work.

Summary of key evidence

Comparing the intervention (action plan) with the control group, there was no evidence that the action plan had a significant effect on any healthcare usage measure, such as GP visits, hospital admissions or emergency department visits.

There was no statistical benefit in health-related quality of life. There was also no difference in respiratory symptoms, anxiety, depression, functional capacity, mortality and lung function.

Over a 12-month period, there was a significant increase in the use of corticosteroids in the action plan group than in the controls.

However, there was no statistically significant difference between the two groups in the chance of being treated with at least one course of corticosteroids for an acute exacerbation.

The chance of being treated with at least one course of antibiotics for an acute exacerbation was significantly greater in the action plan group than in the controls.

One study revealed a significant difference in self-management knowledge in the intervention group, but another found no difference between intervention and control groups.

Best practice recommendations

Providing action plans with limited education is an effective way of improving self-management knowledge in COPD patients. It encourages patients to seek medical advice sooner and more frequently than the usual care group because their knowledge about what exacerbates COPD and the symptoms associated with that exacerbation is better.

But the studies showed that providing action plans with limited education for COPD patients was not recommended as a strategy to decrease healthcare usage, lower mortality or improve quality of life. NT

For the full review report, including references, click here

Author Glenn Carlson is clinical nurse specialist and acute care practitioner, adult critical care, Bronson Methodist Hospital and a member of the Cochrane Nursing Care Field

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