Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e1060 (Published 6 March 2012)
Cite this as: BMJ 2012;344:e1060

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Thanks for the complimentary comments on study design for this study, which based its intervention on the work of Bourbeau and colleagues. It is incorrect to suggest that the intervention only targeted self management of exacerbations – this was a broad based intervention as described in the full paper, conveying general disease management principles as well as advice and training in the management of exacerbations. We used the 6 adapted “Living well with COPD” booklets to train patients on the following topics:
• How COPD causes symptoms
• How regular treatment helps
• How to cope with breathlessness
• How to keep as well as possible – taking control by taking treatment regularly, keeping active and treating exacerbations promptly

Bischoff & Bourbeau ask whether we undertook any exploratory analysis to investigate the attributes of successful self managers – this was not the purpose of the current study and would not have been logistically possible with the large cohort of cases we were managing. I absolutely agree that it should be the target of further investigations and also with the comment that it often takes several exacerbations for a patient to learn to recognise these and react appropriately – an observation which those training patients in asthma self management will recognise. In the study our global judgement of “successful self management” was based on each participant’s response to increased symptoms over the entire 12 month period, and thus allowed for this learning effect.

Further research into the characteristics of successful self management in both asthma and COPD populations is needed, and highlights the issue of research often identifying as many new questions as it provides answers to. In parallel, the studies currently underway using telemedicine approaches should provide complementary information since these studies often remove the need for decision making by patients, thus reducing one of the possible causes of variability.

Competing interests: CEB’s institution received financial support for the employment of a research fellow from Boehringer Ingelheim, GlaxoSmithKline, and Astra Zeneca; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

C E Bucknall, consultant respiratory physician

Department of Respiratory Medicine, Glasgow Royal Infirmary, Glasgow G4 0SF, UK

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We would like to compliment Bucknall et al on the design of their Glasgow supported self-management trial.(1) They showed that they have learned from the flaws of previous conducted self-management studies (2) as their intervention was built on the materials of a proven-effective self-management programme (Living Well with COPD) and aimed to change the behaviour of the individual patient. Moreover, the self-management strategy was supported by nurses who themselves were supported by the research team in training and feedback. Although the authors could not demonstrate any differences between the intervention group and the control group on the primary and secondary outcomes, they showed in an exploratory analysis that a significant minority of patients did benefit from the intervention.

In view of these findings, we have some comments. First, we would like to address that the programme as described by the authors is not a comprehensive COPD self-management programme which aims to improve patient’s behaviour in every aspect of COPD in daily life, but it is an exacerbation self-management programme which only targets self-management behaviour in times of an exacerbation. In this perspective, we think that it was rather ambitious of the authors to expect an improvement of quality of life or self-efficacy, as both outcomes reflect a wider range of aspects than only exacerbation-related.

Second, despite the intensive individual training and the individual support thereafter, only 42% of the patients could be labeled as succesful self-managers. Did the authors explore if these patients had been more adherent to the training sessions and the nurse support than those who were not succesful self-managers? Also, with defining patients as “succesful self-manager”, the authors imply that these patients adhered to their instructions at every exacerbation during the study, i.e., adopted the intended behaviour. However, the intended behaviour of self-managing COPD exacerbations was not measured in the trial. This information would have been of great importance as we want to know if the intervention failed to benefit or failed to intervene.(3) More attention should be given in future studies to measure intermediate outcomes, such as intended behavior change, instead of only measuring ultimate outcomes, such as heath outcomes and health service use. Another limitation of the trial is related to the fact that it often takes more than one exacerbation for the patient to be able to manage an exacerbation succesfully; also, the patient may manage one exacerbation successfully and fail the next exacerbation.(4) This suggests that adherence to self-management instructions takes time. Furthermore, adherence may not only depend on patient characteristics, but perhaps also on exacerbation-related factors, such as exacerbation severity and time to next exacerbation.

So far, many studies have tried to find positive effects of self-management interventions in randomised controlled trials and some of them have succeeded. But the puzzle why programs work or fail to work often remains untouched. Bucknall et al have revealed another piece of the puzzle. If we want to make more progress in our understanding of the effects of COPD self-management strategies, more studies are needed that build on existing and well-designed programmes and focus on the process of self-management behaviour in the individual patient.

References

(1) Bucknall C, Miller G, Lloyd S, Cleland J, McCluskey S, Cotton M et al. Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial. BMJ 2012; 344:e1060.
(2) Effing T, Monninkhof EM, Van der Valk PD, van der Palen J, van Herwaarden CL, Partridge MR et al. Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2007; 4:CD002990.
(3) Bourbeau J, Nault D, Dang-Tan T: Self-management and behaviour modification in COPD . Patient Educ Couns; 2004 Mar;52(3):271-7
(4) Bischoff EW, Hamd DH, Sedeno MF, Benedetti A, Schermer TR, Bernard S et al. Effects of written action plan adherence on COPD exacerbation recovery. Thorax 2011; 66: 26-31 .

Competing interests: None declared

Erik W.M.A. Bischoff, general practitioner (1)

Jean Bourbeau, respiratory physician and epidemiologist (2)

(1) Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein Noord 21, 6525 EZ Nijmegen, the Netherlands; (2) Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University Health Centre, Montréal, Canada

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