D4. Self-management plans

Patients with chronic illness who participate in self-management have better outcomes, including reduced healthcare costs, than those who do not.⁹⁶ This study included some people with COPD. In COPD, behavioural education alone is effective, although less effective than integrated pulmonary rehabilitation programs that include an exercise component.⁹³

In patients with COPD, most exacerbations evolve over days rather than hours, but even small changes can precipitate a major deterioration in functional status. Psychosocial factors such as depression, anxiety, panic or lack of a carer have also been shown to influence the model of care. The traditional approach to exacerbations of moderate to severe COPD has been admission to hospital. Recent work exploring the concept of hospital-at-home has shown that many patients can be managed at home by appropriately qualified staff.^223-225 Whether such treatment is cost-effective remains controversial.^223-225

The concept of self-management plans for patients with COPD is derived from their success in asthma management indicating doses and medications to take for maintenance therapy and for exacerbations. Instructions for crises are often also included. A systematic review by Turnock et al²²⁶ found that the use of action plans results in an increased ability to recognise and react appropriately to an exacerbation by individuals. Unfortunately, there was no evidence these behavioural changes alter health-care utilisation. However, pharmacological treatment of COPD is generally less effective, as the condition is, by definition, non-reversible. Some interventions have strong support (eg, use of bronchodilators and systemic glucocorticoids for exacerbations and antibiotics if there is purulent sputum). They might be more effective if instituted early in an exacerbation, thereby preventing crisis and hospital admission. The primary care team needs to develop systems to identify those with more severe COPD who might benefit from more intensive education and training in self-management skills.

GP involvement in review of self-management plans (including medications) may be undertaken in the context of Domiciliary Medication Management/Review (DMMR), for which a Medicare Benefits Schedule fee is applicable (EPC Item 900). This requires the involvement of an accredited pharmacist and patient consent.

The plan should be reviewed after any exacerbation to make adjustments as appropriate. Patients should be encouraged to start additional treatment at the earliest sign of an impending exacerbation.

D4.1 Maintenance therapy

Detailed discussion of the maintenance therapy for COPD appears in Section O. In general, the use of drugs in COPD does not involve back-titration, which is a core principle in asthma management. The exception is when oral glucocorticoids have been given for an acute exacerbation.

D4.2 Exacerbations and crises

Detailed discussion of the management of exacerbations is found in Section X. For mild to moderate exacerbations, an increase in inhaled bronchodilator therapy and an increase in, or introduction of, inhaled glucocorticoid therapy may be beneficial.

For severe exacerbations there is evidence for the use of bronchodilators, antibiotics, systemic glucocorticoids and supplemental oxygen (if patients are hypoxaemic). Selected patients may benefit from early intervention with these agents according to a predetermined plan developed by a GP or respiratory specialist. Some patients can be instructed to start using a "crisis medication pack" while awaiting medical review. They may also be instructed to contact a particular member of the multidisciplinary care team as part of their overall care plan.

Controlled trials are required to document the efficacy of self-management plans in patients with stable COPD, but, drawing on the success of asthma action plans, education of patients with COPD in self-management is recommended. Written plans are usually required to complement such interventions (see examples at http://www.lungnet.com.au/content/view/1/3/).