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