Action Plan for Chronic Obstructive Pulmonary Desease
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Action plans for chronic obstructive pulmonary disease
(Review)
Turnock AC, Walters EH, Walters JAE, Wood-Baker R
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2006, Issue 3
http://www.thecochranelibrary.com
1Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
T A B L E O F C O N T E N T S
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . .
3SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . .
3METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .
9ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15Characteristics of ongoing studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16Comparison 01. Action Plan versus usual care . . . . . . . . . . . . . . . . . . . . . . . . .
18INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19Analysis 01.01. Comparison 01 Action Plan versus usual care, Outcome 01 Number of admissions to hospital in 12
months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20Analysis 01.02. Comparison 01 Action Plan versus usual care, Outcome 02 Visits to GP/PN in 6 months . . . .
20Analysis 01.03. Comparison 01 Action Plan versus usual care, Outcome 03 Number scheduled GP visits in 12 months
20Analysis 01.04. Comparison 01 Action Plan versus usual care, Outcome 04 Number emergency visits to GP for COPD
in 12 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21Analysis 01.05. Comparison 01 Action Plan versus usual care, Outcome 05 Number of total GP visits in 12 months
21Analysis 01.06. Comparison 01 Action Plan versus usual care, Outcome 06 Number of times treated in the emergency
department in 12 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21Analysis 01.07. Comparison 01 Action Plan versus usual care, Outcome 07 Days on Antibiotics in 6 months . . .
22Analysis 01.08. Comparison 01 Action Plan versus usual care, Outcome 08 Days on corticosteroids in 6 months . .
22Analysis 01.09. Comparison 01 Action Plan versus usual care, Outcome 09 Patients initiating antibiotics in 6 months
23Analysis 01.10. Comparison 01 Action Plan versus usual care, Outcome 10 Patients initiating steroids in 6 months .
23Analysis 01.11. Comparison 01 Action Plan versus usual care, Outcome 11 Courses of Antibiotics in 12 months . .
24Analysis 01.12. Comparison 01 Action Plan versus usual care, Outcome 12 Courses of oral corticosteroids in 12 months
24Analysis 01.13. Comparison 01 Action Plan versus usual care, Outcome 13 Number of subjects with >= 1 exacerbation
COPD with antibiotics in 12 months . . . . . . . . . . . . . . . . . . . . . . . . .
25Analysis 01.14. Comparison 01 Action Plan versus usual care, Outcome 14 Length of exacerbations . . . . . .
25Analysis 01.15. Comparison 01 Action Plan versus usual care, Outcome 15 SGRQ symptom scores at 6 months . .
26Analysis 01.16. Comparison 01 Action Plan versus usual care, Outcome 16 SGRQ activity scores at 6 months . . .
26Analysis 01.17. Comparison 01 Action Plan versus usual care, Outcome 17 SGRQ impact scores at 6 months . . .
27Analysis 01.18. Comparison 01 Action Plan versus usual care, Outcome 18 SGRQ total scores at 6 months . . . .
27Analysis 01.19. Comparison 01 Action Plan versus usual care, Outcome 19 SGRQ symptom scores at 12 months .
28Analysis 01.20. Comparison 01 Action Plan versus usual care, Outcome 20 SGRQ activity scores at 12 months . .
28Analysis 01.21. Comparison 01 Action Plan versus usual care, Outcome 21 SGRQ impact scores at 12 months . .
29Analysis 01.22. Comparison 01 Action Plan versus usual care, Outcome 22 SGRQ total scores at 12 months . . .
iAction plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
29Analysis 01.23. Comparison 01 Action Plan versus usual care, Outcome 23 FEV1 (mls) at 6 months . . . . . .
29Analysis 01.24. Comparison 01 Action Plan versus usual care, Outcome 24 FEV1 (mls) at 12 months . . . . .
30Analysis 01.25. Comparison 01 Action Plan versus usual care, Outcome 25 FEV1 % predicted at 6 months . . .
30Analysis 01.26. Comparison 01 Action Plan versus usual care, Outcome 26 FEV1 % predicted at 12 months . . .
30Analysis 01.27. Comparison 01 Action Plan versus usual care, Outcome 27 FEV1/FVC at 6 months . . . . . .
31Analysis 01.28. Comparison 01 Action Plan versus usual care, Outcome 28 FEV1/FVC at 12 months . . . . .
31Analysis 01.29. Comparison 01 Action Plan versus usual care, Outcome 29 Functional Capacity . . . . . . .
31Analysis 01.30. Comparison 01 Action Plan versus usual care, Outcome 30 Number of days symptoms recorded in 6
months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32Analysis 01.31. Comparison 01 Action Plan versus usual care, Outcome 31 Days of breathing recorded as usual in 6
months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32Analysis 01.32. Comparison 01 Action Plan versus usual care, Outcome 32 Days of breathing recorded as mild in 6
months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32Analysis 01.33. Comparison 01 Action Plan versus usual care, Outcome 33 Days of breathing recorded as moderate in 6
months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33Analysis 01.34. Comparison 01 Action Plan versus usual care, Outcome 34 Days of breathing recorded as severe in 6
months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33Analysis 01.35. Comparison 01 Action Plan versus usual care, Outcome 35 Mortality . . . . . . . . . . .
34Analysis 01.36. Comparison 01 Action Plan versus usual care, Outcome 36 Days lost from work . . . . . . .
34Analysis 01.37. Comparison 01 Action Plan versus usual care, Outcome 37 HADS anxiety . . . . . . . . .
34Analysis 01.38. Comparison 01 Action Plan versus usual care, Outcome 38 HADS depression . . . . . . . .
35Analysis 01.39. Comparison 01 Action Plan versus usual care, Outcome 39 SMI well knowledge . . . . . . .
35Analysis 01.40. Comparison 01 Action Plan versus usual care, Outcome 40 SMI well actions . . . . . . . . .
35Analysis 01.41. Comparison 01 Action Plan versus usual care, Outcome 41 SMI early exacerbation knowledge . .
36Analysis 01.42. Comparison 01 Action Plan versus usual care, Outcome 42 SMI early exacerbation actions . . . .
36Analysis 01.43. Comparison 01 Action Plan versus usual care, Outcome 43 SMI severe exacerbation knowledge . .
36Analysis 01.44. Comparison 01 Action Plan versus usual care, Outcome 44 SMI severe exacerbation actions . . .
iiAction plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Action plans for chronic obstructive pulmonary disease(Review)
Turnock AC, Walters EH, Walters JAE, Wood-Baker R
This record should be cited as:
Turnock AC, Walters EH, Walters JAE, Wood-Baker R. Action plans for chronic obstructive pulmonary disease. Cochrane Database ofSystematic Reviews 2005, Issue 4. Art. No.: CD005074. DOI: 10.1002/14651858.CD005074.pub2.
This version first published online: 19 October 2005 in Issue 4, 2005.
Date of most recent substantive amendment: 23 July 2005
A B S T R A C T
Background
The effectiveness of action plans as treatment for chronic obstructive pulmonary disease (COPD) is not known.
Objectives
To assess the efficacy of action plans in the management of COPD.
Search strategy
We searched the Cochrane Airways Group Specialised Register, CENTRAL, MEDLINE, CINAHL and the National Research Register
of Ongoing Trials. We also searched reference lists of identified studies. The search was completed in August 2004.
Selection criteria
Randomised controlled trials of action plans in COPD. Studies with a primary diagnosis of asthma excluded.
Data collection and analysis
Two reviewers independently assessed trial quality and extracted data. Investigators were contacted for additional information when
necessary. Study results were combined in meta-analyses using the Cochrane Collaboration software RevMan.
Main results
There was evidence of a positive effect of action plans on self-management knowledge. The mean difference (MD) for recognition of a
severe exacerbation was 2.50; 95% confidence interval 1.04 to 3.96, for self-action in severe exacerbations MD 1.50; 95% confidence
interval 0.62 to 2.38 and the use of antibiotics MD 6.00; 95% confidence interval 2.68 to 9.32. There was also evidence of a positive
effect on the initiation of antibiotics (odds ratio (OR) 10.16; 95% confidence interval 2.02 to 51.09) and/or oral steroids (OR 6.58;
95% confidence interval 1.29 to 33.62). However, there was no evidence of significant effects on healthcare utilisation, health-related
quality of life, lung function, functional capacity, symptom scores, mortality, anxiety, or depression. No trials used as outcomes: number
of exacerbations, length of exacerbations, or days lost from work.
Authors’ conclusions
This review shows there is evidence that action plans aid people with COPD in recognising and reacting appropriately to an exacerbation
of their symptoms via the self-initiation of antibiotics or steroids. Further research needs to be completed with more comprehensive
outcomes measures in order to ascertain whether this results in significantly decreased morbidity and/or mortality.
P L A I N L A N G U A G E S U M M A R Y
Chronic obstructive pulmonary disease (COPD) is a progressive disease characterised by exacerbations of symptoms which decrease
quality of life. Action plans are designed to help an individual recognise a deterioration in their symptoms and initiate changes to
treatment early. This is designed to reduce the impact of the exacerbation.
1Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
This review 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.
B A C K G R O U N D
Chronic obstructive pulmonary disease (COPD) is a progressive
respiratory condition usually related to cigarette smoking. The
prevalence of COPD was estimated to be 10.2 million or 5.9% of
the population in adults >25 years old in the United States in 1997
(Mannino 2002). Worldwide, COPD is expected to move up from
the 12th leading cause of disability-adjusted life-years (DALYs) in
1990 to the fifth leading cause in 2020 (Mannino 2002). Thus
COPD places a strain on patients, families, carers and the whole
community. It is a costly disease in terms of loss of quality of life,
decreased ability to contribute to society, and economic costs. The
estimated direct medical costs of COPD in the United States in
1993 was US$14.7 billion (Mannino 2002).
Historically, there has been debate over the definition and criteria
for the diagnosis of COPD, as well as uncertainty about its treat-
ment. The global initiative for chronic obstructive lung disease
(GOLD) criteria define COPD as a disease state characterised by
airflow limitation that is not fully reversible. The airflow limitation
is usually progressive and associated with an abnormal inflamma-
tory response of the lungs to noxious particles or gases (Pauwels
2001). The presence of a post-bronchodilator FEV1 <80% of the
predicted value in combination with an FEV1/FVC <70% con-
firms the presence of airflow limitation that is not fully reversible
(Pauwels 2001).
A major problem associated with COPD is the occurrence of ex-
acerbations, or periodic worsening of symptoms and lung func-
tion. Symptoms during exacerbations include increased shortness
of breath, cough and sputum production. These exacerbations re-
sult in increased utilisation of healthcare services, and decline in
health-related quality of life. They are usually managed with in-
creased bronchodilator medication, oral corticosteroids and an-
tibiotics. Early identification and treatment of exacerbations is im-
portant, although studies have shown that only up to 60% of exac-
erbations are reported to a healthcare provider (Wilkinson 2004).
The use of ’action plans’ aims to encourage early intervention.
They do this by providing guidelines on how to recognise an ex-
acerbation via symptoms, sometimes with associated lung func-
tion changes. This is used to define when to alter the medication
regime and visit healthcare providers. However, the evidence to
support the use of action plans in COPD at present is limited.
While action plans have been proven effective in the management
of asthma, their role in COPD is unclear. It cannot necessarily be
assumed that an action plan will have the same effect in COPD
as in asthma. For example, although it has been shown that asth-
matics who received a patient brochure and two two-hour group
education sessions had improved steroid inhaler compliance com-
pared to control asthmatics, COPD patients were unaffected by a
similar intervention (Gallefoss 1999).
As patients who receive prompt therapy after the onset of an ex-
acerbation recover sooner and COPD patients who consistently
neglect treatment for their exacerbations have a poorer quality of
life (Wilkinson 2004), any intervention that leads to better and
earlier intervention for exacerbations would be expected to have a
beneficial effect on health-related quality of life. However, studies
of self-management of COPD involving combinations of educa-
tion programs, brochures, exercise programs, and action plans have
produced varied results, ranging from inconclusive (Monninkhof
2003), to beneficial (Bourbeau 2003 (2); Worth 2004). They have
also failed to identify which components of comprehensive self-
management interventions are most effective (Bourbeau 2003 (1);
Bourbeau 2004), specifically whether action plans are beneficial
(Monninkhof 2003). This review aims to determine whether ac-
tion plans alone, or as part of a broader self-management inter-
vention, are an effective way to manage COPD exacerbations.
O B J E C T I V E S
The primary objective for this review was to determine whether
action plans for the management of exacerbations improve health
outcomes in people with COPD.
C R I T E R I A F O R C O N S I D E R I N G
S T U D I E S F O R T H I S R E V I E W
Types of studies
Randomised controlled trials (RCTs), excluding cross-over trials.
Types of participants
Participants were all patients with primary COPD diagnosed by
a health practitioner using spirometric criteria such as those of
GOLD. Thus participants must have had a FEV1 <80% of pre-
dicted value, and a FEV1/FVC <70% of the predicted value. They
must also have had a history of smoking. Studies with participants
who had a primary diagnosis of asthma were identified and ex-
cluded.
Types of intervention
The intervention in this study was the use of an action plan, de-
fined as the use of guidelines which outline self-initiated interven-
tions (such as changing medication regime or visiting the GP or
2Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
hospital) which are undertaken appropriately in response to alter-
ations in the state of the patients’ COPD (e.g. increase in breath-
lessness, increased amount or purulence of sputum) that suggest
the commencement of an exacerbation. Broader self-management
plans, which include primary interventions such as education and
exercise programs were not included, irrespective of whether they
included an action plan. The active intervention was compared to
’usual care’.
Types of outcome measures
Primary outcomes included:
1. Hospital admission
2. Healthcare utilisation: scheduled and unscheduled GP visits;
treatment in an emergency department
3. Use of medications: number of courses and days of antibiotic
and/or steroid use; number of participants initiating antibiotic
and/or steroid use
Secondary outcomes included:
1. Number of acute exacerbations
2. Length of exacerbations
3. Health related quality of life (HRQoL) using the St George’s
Respiratory Questionnaire (SGRQ)
4. Lung function
5. Functional capacity
6. Symptom scores
7. Mortality
8. Days lost from work
Additional outcomes:
1. Anxiety and depression scores using the Hospital Anxiety and
Depression scale (HADS)
2. Standardised self management interview for COPD (SMI)
S E A R C H M E T H O D S F O R
I D E N T I F I C A T I O N O F S T U D I E S
See: Airways Group methods used in reviews.
RCTs were identified using the Cochrane Airways Group
Specialised Register of RCTs. The Register’s records coded as
’COPD’ were searched using the following terms:
“action plan*” OR action-plan* OR self-car* OR “self car*” OR
self-manag* OR “self manag*” OR “management plan*” OR
management-plan* OR “management program*” OR behaviour*
OR behavior* OR educat*
A total of 197 references were found.
An advanced search on the Collaborations trial register
CENTRAL was carried out using the terms:
(Pulmonary disease, chronic obstructive) AND (self care OR
self administration OR self-evaluation programs OR models
educational OR cooperative behavior OR health behavior)
This search retrieved 8 references, none of which added to those
identified by the Airways Register search.
A direct search of CINAHL was completed using the search
terms:
(EXP(“Lung diseases, obstructive”) AND (“self care” OR “self-
care” OR “patient education” OR “behavioral changes” OR
“behavioral objectives”) AND EXP(“clinical trials”)
This search retrieved 77 references, none of which added to those
identified by the Airways Register search.
A direct search of MEDLINE via PubMed was completed using
the search:
“Pulmonary Disease, Chronic Obstructive”[MeSH] AND
(“self care”[MeSH] OR “patient education”[MeSH] OR
“Models, Educational”[MeSH] OR “Patient Education
Handout”[Publication Type] OR “Behavior”[MeSH]
OR “Behavior Therapy”[MeSH] OR “Cooperative
Behavior”[MeSH] OR “Behavior control”[MeSH] OR
“Behavioral Medicine”[MeSH] OR “Health Promotion”[MeSH]
This search was limited to RCTs and retrieved 53 references,
none of which added to those identified by the Airways Register
search.
A direct search of the National Research Register of Ongoing
Trials was also completed. The terms used were:
((pulmonary disease, chronic obstructive) AND ((action plan*)
OR action-plan* OR self-car* OR (self car*) OR self-manag* OR
(self manag*) OR (management plan*) OR management-plan*
OR (management program*) OR behaviour* OR behavior* OR
educat*))
This retrieved 23 records. One record had not been identified by
the search of the Airways Register.
From the full text papers obtained, the bibliographic lists were
hand searched for additional articles. This revealed no additional
articles. We also contacted researchers for information about
their ongoing trials.
M E T H O D S O F T H E R E V I E W
Titles, abstracts and citations were reviewed to assess relevance for
full review. Full text articles were reviewed and assessed by two
independent reviewers to determine inclusion or exclusion based
on the criteria set down for considering studies for this review (see
above), and grade of allocation concealment. Jadad score was also
assessed.
Any discrepancies were resolved via consensus between reviewers.
Data extraction
Two reviewers (AT & JW) independently extracted the data
(using a standardised form) considering the study population,
interventions and primary and secondary outcomes.
3Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Included studies were then assessed for quality by the two
reviewers. Any discrepancies were again resolved via consensus.
Allocation concealment was first assessed in accordance with the
Cochrane approach. Each trial was given a score:
Grade A - adequate; i.e. formal randomisation using sealed
envelope
Grade B- unclear; uncertain or unclear concealment
Grade C- inadequate; clearly inadequate concealment, i.e.
assignment by alternation
As it was not possible for the trials to be double-blinded the
maximum Jadad score obtainable was three. Trials were evaluated
by sensitivity analysis using quality grades.
Analysis
The review included only RCTs in the analysis. Outcomes were
analysed as binary or continuous outcomes as appropriate for the
distribution of the data and used standard statistical techniques.
Cluster trials were combined using generic inverse variance (GIV)
method.
For dichotomous outcomes, the odds ratio was calculated with
95% confidence intervals by the method of Peto.
For continuous outcomes, the weighted mean difference and 95%
confidence intervals were calculated.
A funnel plot was constructed to identify possible asymmetry
suggesting publication bias.
Heterogeneity was explored. If significant heterogeneity existed,
subgroup analysis of severity of COPD was to be done.
We obtained the effect estimates (mean difference or odds/risk
ratio) and the 95% confidence interval (CI) for dichotomous and
continuous outcomes by entering data into the appropriate tables
for analysis in Rev Man. This enabled us to combine individually
randomised and cluster trials using the GIV. The 95% CI was
converted to SE using the equation:
SE = (upper limit - lower limit)/3.92
When data were expressed as a % of each group with one or more
episodes of health-care utilisation we calculated the number of
episodes (n) from the number of participants in the group (N).
Using RevMan an OR and 95% CI were obtained and the In(OR)
and In(SE) calculated.
In(OR) = InOR In(SE) = (In(upper limit)-In(lower limit))/3.92
Effect size = In(OR)/1.81 Standard error = In(SE)/1.81
Where 3.92 is 2 x 1.96 standard errors wide and calculates the
95% confidence interval.
To re-express the log odds ratio as standardised mean difference
divide by π/√3=1.81.
When data included a P value, the number of participants in the
both groups (Ne and Ni), and score for each group, the mean
difference(MD) was calculated, and the following procedure was
undertaken to arrive at the estimate and standard error.
t-statistic = tinv(P value, degrees of freedom) where degrees of
freedom = (Ne+Ni)-2
SE of MD = MD/t-statistic SD=SE of MD/(√(1/Ne +
1/Ni))
Once entered into RevMan, we can obtain the weighted mean
difference (WMD) and 95% CI and thus calculate the SE via the
equation:
SE = (upper limit - lower limit)/3.92
Where 3.92 is 2 x 1.96 standard errors wide and calculates the
95% confidence interval.
D E S C R I P T I O N O F S T U D I E S
See: Table of included studies.
Three studies were included in the review, McGlone 2004 was
a prospective parallel-group cluster randomised study; McGeoch
2004 was a prospective cluster randomised controlled trial; Watson
1997 was a parallel-group block randomised controlled study. All
studies recruited participants through general practitioners (GPs),
McGlone 2004 recruited from 54 GPs and Watson 1997 recruited
from 22 GPs. McGeoch 2004 also identified patients through pre-
scription databases of bronchodilators and inhaled corticosteroid
prescriptions to increase number of patients screened.
Baseline participant characteristics revealed that all the studies in-
volved people of a similar age. There were more male participants
in all studies, with significantly more in McGlone 2004 (73% in
intervention, 93% in control). The percentage of current smokers
in each group varied, with 24% in intervention and 33% in con-
trol still smoking in Watson 1997, 53% in intervention and 30%
in control still smoking in McGlone 2004, and 31% in interven-
tion and 23% in control still smoking in McGeoch 2004. The
FEV1% predicted varied slightly between groups in all studies:
37% (SD 14) intervention and 36% (SD 16) control in Watson
1997, 46.3% (SD 16) intervention and 44.2% (SD 15.8) con-
trol in McGlone 2004, and 54.6% (SD 18,7) intervention and
53.1% (SD 18.1) control in McGeoch 2004. According to the
COPDX plan McKenzie 2003, which are Australian and New
Zealand guidelines on the diagnosis and management of COPD,
this places the mean of participants in the Watson 1997 in the se-
vere COPD grouping and in McGeoch 2004 and McGlone 2004
in the moderate COPD category. In terms of baseline SGRQ the
scores were similar between groups.
All studies required participants to fit diagnostic criteria for COPD
as their major functionally limiting disease, as defined by the Amer-
ican Thoracic Society (ATS); smoking history of greater than 10
pack-years, and FEV1/FVC ratio <70%. McGlone 2004 partici-
pants also had to fit the criteria: aged more than 50 years. Both
Watson 1997 and McGlone 2004 also required a FEV1 <65% of
predicted. McGeoch 2004 also stated inclusion criteria of symp-
toms at least weekly and history of one or more exacerbations in
the previous 12 months requiring an increase in therapy. Entry
criteria for Watson 1997 included current use of bronchodilator
therapy.
4Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
In all studies nursing home residents were excluded. Watson 1997
and McGeoch 2004 had additional exclusion criteria, including
primary diagnosis of asthma (onset <35 years). Watson 1997 spec-
ified a primary diagnosis of cardiac disease (uncontrolled heart fail-
ure), primary or secondary diagnosis of another functionally lim-
iting disease (except cor pulmonale) that could significantly affect
either patient mortality within six months of entry to the study
or participation in the study, and continuous use of oral corticos-
teroid or long-term antibiotic therapy as exclusion criteria. Mc-
Geoch 2004 excluded participants with another primary limiting
disease, another medical condition likely to affect patient mortal-
ity, if already using a self-management plan, on domiciliary oxy-
gen, attending a GP that used self-management plans more than
occasionally, exacerbation of COPD requiring increased treatment
within six weeks or admission to a general hospital within three
months, cognitive impairment, alpha1 antitrypsin deficiency, or
being unable or unwilling to sign consent form.
In McGlone 2004 patients were randomised using a computer
generated randomisation software package at the general practice
level so that all participants from individual practices were given
the same intervention. Randomisation in Watson 1997 was gen-
erated via a computer in blocks of ten. Allocation concealment
grades were B for both trials. In McGeoch 2004, the GP practices
were randomised by one of the investigators, and if there were
too many patients identified in each practice, a random numbers
table was used to allocate individual patients. The allocation con-
cealment in this trial was thus B. One aspect of concern with this
method is that if the same GP is implementing both intervention
and usual care there may confounding between treatment meth-
ods, possibly diluting the effects of active intervention.
The interventions in Watson 1997, McGeoch 2004 and McGlone
2004 all involved the use of an action plan and an information
booklet. McGlone 2004 participants also received an individual
education session with a nurse experienced in managing respi-
ratory disease. Their action plan was a written self-management
plan that was developed in consultation with their treating GP. It
listed the patient’s maintenance medications and an individualised
action plan based on the early recognition of symptoms associ-
ated with exacerbations of COPD. Seventy six per cent received
a standard action plan with instructions to self-initiate a short-
course of oral corticosteroids and an antibiotic, whilst the other
24% received an action plan with instructions to either initiate an-
tibiotics only (n=10), double their dose of inhaled corticosteroids
and commence an antibiotic (n=2), initiate a short course of oral
corticosteroids only (n=1) or to contact their GP (n=3). Those
action plans that involved self-initiation of medication were given
prescriptions by their GP. All intervention participants were en-
couraged to present early to their GP.
The action plans used in Watson 1997 and McGeoch 2004 were
exactly the same and provided advice on management of usual care
and exacerbations, together with a booklet on self-management, a
prescription for prednisolone and a broad spectrum antibiotic for
self-administration during an exacerbation from their GP. Watson
1997 made no attempt to individualise the instructions in the
action plan, whereas standardised self-management plan education
was delivered in an individual session from a practice nurse or
respiratory educator in association with the participant’s GP in the
McGeoch 2004 trial.
Booklets were supplied with action plans that covered the topics of
smoking cessation, controlling breathlessness, nutrition, exercise,
clearing mucus from the lungs, medications, and contact details of
community support services. Watson 1997 and McGeoch 2004
also covered other topics; daily activities made easier, sleep, plan-
ning for the future, and oxygen therapy. McGlone 2004 also in-
cluded the basic pathology of COPD, immunisations, stress man-
agement, and the correct use of inhalers.
All control groups were provided with usual care, and although
this varied between studies they were always specifically denied
access to the action plan. In McGlone 2004, usual care included
provision of a booklet and an individual nurse education session. In
McGeoch 2004, non-standardised education according to routine
practice at the time was provided and in Watson 1997 there was
no educational intervention.
Outcome measures in the McGlone 2004 study were assessed at
baseline, 3, 6, 9, and 12 months. The 6 and 12 month assessments
were face-to-face at the GPs surgery or patient’s home, whilst the 3
and 9 month were done using a standardised telephone interview.
Demographics, smoking and symptom history, medications used
as maintenance and treatment over the preceding 12 months were
obtained at baseline from a standardised questionnaire. Height,
weight and spirometry were recorded at baseline, 6 and 12 months.
In Watson 1997 outcomes were measured at 6 and 12 months, and
reported as absolute means and standard deviations from baseline.
Both studies assessed HRQoL via SGRQ at baseline and six
months. However, Watson 1997 reported absolute mean and stan-
dard deviation, whilst McGlone 2004 reported mean change and
standard deviation at 6 and 12 months after having reported ab-
solute mean and standard deviation at baseline.
Other outcome measures assessed by McGlone 2004 included
physical activity over 7 days using a digital pedometer at baseline, 6
and 12 months; a diary record for use of antibiotics, short courses
of oral steroids, number of GP consultations, hospitalisations, and
attendances at emergency departments. Diary cards and smoking
status were reviewed at three monthly intervals.
Other outcome measures assessed by Watson 1997 included daily
diary cards which rated respiratory status as usual, mild, mod-
erate, or severe; prednisone use, antibiotic use, and contact with
GP, PN, hospital specialist, pharmacist. Subjects were interviewed
about access to and use of treatments, services and self-manage-
ment strategies. FEV1 and FVC were measured with a spirom-
eter. Application of outcome measures were delayed if subjects
5Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
had received a course of prednisone or antibiotics in the preced-
ing 21 days. McGeoch 2004 included study visits at baseline and
12 months, with telephone interviews at 3, 6, and 9 months. At
6 and 12 months the SGRQ, healthcare utilisation and medica-
tion scores were recorded. HADS was recorded at baseline and 12
months. The absolute COPD-SMI was recorded at 12 months.
Any missing data was addressed by contacting the author for ad-
ditional information. If there was no reply on the first occasion a
second attempt was made.
M E T H O D O L O G I C A L Q U A L I T Y
The allocation concealment grade for all studies was B, interpreted
as concealment being unclear. In Watson 1997, the randomisa-
tion list was available to the person recruiting the GPs and par-
ticipants, but not the participants or GPs themselves who found
out upon beginning the programme. In McGlone 2004, GPs were
randomised and aware of the arm they were randomised to. In
McGeoch 2004, the GP practices were randomised by one person
and if there were too many patients identified in each practice a
random numbers table was used to allocate individual patients.
None were double blind due to the nature of the study making it
impossible. A description of withdrawals and dropouts was given
in all studies.
R E S U L T S
INCLUSION
The searches identified a total of 199 titles and abstracts that
were screened to identify potential relevance to the topic of action
plans in COPD. Eleven studies appeared relevant to the review
and two reviewers (AT and JW) assessed them independently. Of
these, two are ongoing (Brightling; Sweeney 2002), two are com-
pleted but data could not be obtained either in published form
or from the investigators (Prigmore 2001; Wellingham 2002) and
four were excluded. Two were not randomised controlled trials
(Dhein 2003; Parenteau 2003) and two were comprehensive pro-
grammes in which the action plan component could not be iso-
lated (Bourbeau 2004; Worth 2004). Three articles were included
in the meta-analysis (McGeoch 2004; McGlone 2004; Watson
1997).
MISSING DATA
Authors were contacted twice via e-mail to request missing data.
Those listed in the acknowledgment section replied and were able
to provide requested information. Replies were not received from
two ongoing studies nor one full-text article.
INTERVENTIONS
All studies compared action plans with usual care, and all also
used an information booklet. McGeoch 2004 and Watson 1997
used the same action plan, whilst McGlone 2004 used a slightly
more personalised action plan for the patients. Education provided
with action plans included an individual education session with a
health-care worker in McGlone 2004 and McGeoch 2004, and an
unstandardised introduction to action plans upon presentation of
the action plan in Watson 1997. Follow-up time in Watson 1997
was six months, whilst in McGeoch 2004 and McGlone 2004 it
was 12 months. McGlone 2004 also recorded some outcomes at
six months.
COMPARISONS
All included studies used an action plan as the active intervention
and this was specifically denied to participants in the control group.
SUBJECTS/RECRUITMENT
A total of 367 patients were randomised in the three studies; 320
completed the studies. The drop out rate ranged from 4.4% to
18.8%.
All studies recruited from GP clinics. McGeoch 2004 recruited
additional participants from prescription databases, searching for
bronchodilator and inhaled corticosteroid prescriptions.
HETEROGENEITY AND SENSITIVITY ANALYSIS
No heterogeneity was identified. Nothing was revealed in sensi-
tivity analysis.
OUTCOMES
Number of studies reporting the outcome is given in brackets:
Primary outcomes:
A1. Hospital admission (3)
A2. Healthcare utilisation (3) specifically: scheduled and unsched-
uled GP visits; treatment in an emergency department.
A3. Use of medications (3) specifically: number of courses/days
of antibiotic and/or steroid use; number of participants initiating
antibiotic and/or steroid use
Secondary outcomes:
B1. Number of acute exacerbations (0)
B2. Length of exacerbations (0)
B3. HRQoL (3)
B4. Lung function (2)
B5. Functional capacity (1)
B6. Symptom scores (1)
B7. Mortality (2)
B8. Days lost from work (0)
Additional outcomes reported:
C1. Anxiety and depression (1)
C2. Self management knowledge(1)
A1. HOSPITAL ADMISSION
In McGeoch 2004 8% of the intervention group and 9% of the
usual care group had one or more hospital admissions over 12
months. In McGlone 2004 the mean number of hospital admis-
sions over 12 months was 0.5 (SD 0.8) for the intervention group
and 0.3 (SD 0.7) for the usual care group. Pooling the data found
no evidence of a significant effect of active intervention for this
6Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
outcome: weighted mean difference in number of admissions over
12 months from two studies was 0.16; 95% confidence interval
-0.09 to 0.42.
A2. HEALTHCARE UTILISATION
No significant difference in healthcare utilisation was seen between
groups for any type of healthcare utilisation:
Number of visits to GP or practice nurse in six months, WMD
1.00; 95% confidence interval -0.57 to 2.57 (two studies)
Number of scheduled visits to GP in 12 months, mean difference
-0.50; 95% confidence interval -4.06 to 3.06 (one study)
Number of emergency visits to GP for COPD in 12 months,
mean difference -0.20; 95% confidence interval -1.55 to 1.15 (one
study)
Number of emergency department visits in 12 months, WMD
-0.01; 95% confidence interval -0.12 to 0.10 (two studies)
A3. USE OF MEDICATIONS
The use of medications was reported in a variety of ways. Watson
1997 measured use of medications over six months and showed
a significant increase in the use antibiotics by the group using an
action plan. The mean difference in number of days on antibi-
otics was 6.00 days; 95% confidence interval 1.4 to 10.6, and
the Peto odds ratio for the initiation of corticosteroid was 6.51;
95% confidence interval 2.02 to 21.05. The difference between
groups was not as clear cut for oral corticosteroid use. The num-
ber of days on corticosteroids was not statistically significant be-
tween groups, mean difference 6.00 days; 95% confidence interval
-5.53 to 17.53, while the number of participants initiating corti-
costeroids was, Peto odds ratio 4.85; 95% confidence interval 1.37
to 17.21. McGlone 2004 and McGeoch 2004 both reported this
outcome using continuous data over 12 months, which could be
combined. There was no significant difference in medication use
for either antibiotics over 12 months; WMD 0.14 courses, 95%
confidence interval -0.20 to 0.48 or for oral corticosteroids over
21 months; WMD 0.35 courses, 95% confidence interval -0.17
to 0.88. The large weight allocated to McGeoch 2004 (94.76%)
is due to the small confidence interval. Attempts were made to
combine use of medications across all three trials, but the available
data did not permit this.
B1. NUMBER OF ACUTE EXACERBATIONS
None of the studies included measured the number of acute exac-
erbations using criteria such as those of Seemungal 2000, which re-
quires an increase in two of the “major symptoms”; dyspnoea, spu-
tum volume or sputum purulence, or one of these with an increase
in one “minor symptom” for two days (wheeze, sore throat, cough
or common cold symptoms). While McGlone 2004 reported that
83% of the intervention group and 67% of the usual care group
were treated for an exacerbation of COPD during 12 months, and
this difference was statistically significant, Peto odds ratio 2.44;
95% confidence interval 1.14 to 5.23, it should be borne in mind
that using treatment of an exacerbation as a surrogate for the total
number may underestimate the frequency as up to 40% are not
be reported to a health care provider ( Wilkinson 2004).
B2. LENGTH OF EXACERBATIONS
No studies reported this outcome
B3. HRQoL
Health-related quality of life was measured using the COPD-spe-
cific St George’s Respiratory Questionnaire (SGRQ) in all studies.
We combined the results from Watson 1997 and McGlone 2004.
At six months there were no statistically significant differences be-
tween groups for HRQoL.
Overall score: WMD -1.91; 95% confidence interval -5.46 to 1.63
Symptoms: WMD -4.78; 95% confidence interval -10.81 to 1.24
Activity: WMD -2.43; 95% confidence interval -7.37 to 2.50
Impacts: WMD -0.62; 95% confidence interval -4.45 to 3.21
Combining results from McGlone 2004 and McGeoch 2004 at 12
months also showed no statistically significant difference between
groups for HRQoL.
Overall score: WMD -0.32; 95% confidence interval -3.34 to 2.70
Symptoms: WMD 1.87; 95% confidence interval -3.27 to 7.00
Activity: WMD -2.82; 95% confidence interval -6.84 to 1.19
Impacts: WMD 1.16; 95% confidence interval -2.21 to 4.53
B4. LUNG FUNCTION
There were no statistically significant differences between inter-
ventions in lung function at either 6 or 12 months.
FEV1 ml at six months: mean difference 50.00 ml; 95% confi-
dence interval -29.86 to 129.86 (1 study)
% predicted FEV1 at six months: WMD 1.83 %; 95% confidence
interval -1.05 to 4.71 (2 studies)
FEV1 ml at 12 months: mean difference 43.00 ml; 95% confi-
dence interval -63.30 to 149.30 (1 study)
% predicted FEV1 at 12 months: mean difference 2.00 %; 95%
confidence interval -1.89 to 5.89 (1 study)
B5. FUNCTIONAL CAPACITY
Functional capacity was recorded in the McGlone 2004 study as
physical activity steps/day. No significant difference was found.
B6. SYMPTOM SCORES
There were no statistically significant changes in symptom scores
in the one study reporting this outcome Watson 1997. The mean
difference in the number of days with respiratory symptoms in
six months was -16.00 days; 95% confidence interval -45.65 to
13.65. Subjects breathing status was recorded in symptom diaries
on a four point scale (usual, mild, moderate, severe). There were
no significant differences in the percentage of days recorded as
mild, moderate or severe. Both groups had 8% of days in which
breathing was recorded as “severe”.
B7. MORTALITY
The difference in mortality was not statistically significant, Peto
odds ratio at 12 months 1.01; 95% confidence interval 0.32 to
3.24 McGeoch 2004; McGlone 2004.
7Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
B8. DAYS LOST FROM WORK
No studies reported this outcome
C1. ANXIETY AND DEPRESSION
No statistically significant differences between groups were found
in McGeoch 2004 using the HADS. The mean difference for
anxiety was 0.14; 95% confidence interval -1.66 to 1.94 and for
depression was 0.25; 95% confidence interval -0.59 to 1.09.
C2. SELF MANAGEMENT
Using a standardised COPD self management questionnaire, Mc-
Geoch 2004 showed a statistically significant difference in partic-
ipants’ knowledge favouring the action plan group. For recogni-
tion of when respiratory health is stable, the mean difference was
1.10; 95% confidence interval 0.46 to 1.74; for recognition of an
early exacerbation the mean difference was 1.80; 95% confidence
interval 0.75 to 2.85 or a severe exacerbation, mean difference
2.50; 95% confidence interval 1.04 to 3.96. There was also a sta-
tistically significant difference for knowledge on how to act when
each of these states of health is being experienced, again favouring
the action plan group. The mean difference when well was 0.50;
95% confidence interval 0.21 to 0.79, for an early exacerbation
was 2.30; 95% confidence interval 0.96 to 3.64 and for a severe
exacerbation was 1.50; 95% confidence interval 0.62 to 2.38. This
study shows patients have a better knowledge of the importance of
early intervention, and how to implement appropriate treatment
for an exacerbation if they are provided with an action plan.
D I S C U S S I O N
This paper systematically reviewed the literature comparing action
plans to usual care for COPD. From the three studies included,
there was no evidence of effect on healthcare utilisation, HRQoL,
lung function, functional capacity, symptom scores, mortality,
anxiety and depression. Evidence of a positive effect was seen in
one primary (medication usage) and one additional outcome (self-
management). The number of exacerbations, length of exacerba-
tions, and days lost from work were not recorded outcomes in any
of the trials.
For the primary outcomes, hospital admissions showed no signif-
icant difference between interventions. The two studies involved
in this analysis moved in opposite directions and interpretation of
the mean difference, 0.16 per year; 95% confidence interval -0.09
to 0.42, is unclear. Similarly, other healthcare utilisation showed
no statistical differences for the number of emergency GP visits
or visits to the emergency department . However, for the final pri-
mary outcome, a statistically significant increase in medication use
was seen favouring the action plan group. We suggest this repre-
sents an appropriate response to recognition of an acute exacerba-
tion, given that the active interventions in the studies were to ini-
tiate treatment with antibiotics and/or corticosteroids (McGeoch
2004; McGlone 2004), or subjects were supplied with these drugs
for use (Watson 1997). Further evidence to support the argument
that this represents a positive outcome for action plans is seen
in the McGeoch 2004 cluster trial, in which a greater ability to
recognise and appropriately react to symptoms suggesting an ex-
acerbation, was seen in the action plan arm. Given that there is ev-
idence from a systematic review that treatment of an exacerbation
of COPD with oral steroids reduces the risk of treatment failure,
improves FEV1 and breathlessness (Wood-Baker 2003) and that
oral steroids shorten the time to recovery from an exacerbation
(Seemungal 2000), it is disappointing that there was no evidence
that this translated into positive effects on other outcomes, and
questions whether action plans impact significantly upon patients’
health status. While an increased use of antibiotics and steroids
suggests greater self-initiation of medications as part of an action
plan, this also exposes patients to adverse effects including an in-
crease in bacterial resistance, and side effects of the drugs e.g. os-
teoporosis, which were poorly reported in all studies. Although
confounding is a potential problem in the Watson 1997 study, due
to self-selection of GPs with an interest in COPD who may be
more likely to treat severe COPD with antibiotics or prednisone
in the absence of an action plan, this should have been overcome
by the use of cluster randomisation in the later McGlone 2004
and McGeoch 2004 trials.
For secondary outcomes, neither the number or length of exacer-
bations were reported directly. HRQoL showed no significant dif-
ference in either the total or any sub-category at 6 or 12 months.
This absence of a difference between interventions in HRQoL was
mirrored by lung function and physical activity in the McGlone
2004 study. Given the known associations between lung func-
tion, HRQoL and physical activity, the absence of an improve-
ment in HRQoL without associated changes in other outcomes,
is not surprising. The decreased physical activity of both interven-
tion groups seen in McGlone 2004 study could be due to progres-
sion of COPD over the 12 months, unlikely given the stable lung
function, or be the result of other factors such as seasonal weather
variation. It is not impossible that the 6 and 12 month scores may
have been recorded in summer and winter months, accounting for
the changes in physical activity scores.
All the studies included in this review had methodological limita-
tions. None of the three studies achieved a grade A allocation con-
cealment, which highlights the main limitation. However, alloca-
tion concealment was traded off against potential confounding by
contamination within GP groups in the two later studies, after this
had been identified as an issue by Watson 1997. Although Mc-
Geoch 2004 reported undertaking cluster randomisation of GPs,
further information revealed that if the numbers of individuals
participating in the study were too large for the practice involved,
the individuals were then randomised via a random numbers ta-
ble. This effectively defeats the purpose of cluster randomisation
to reduce contamination.
Most of the reported outcomes were small and did not reach statis-
8Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
tical significance. This may reflect small numbers of participants
in each study and/or the ability to statistically combine many of
the outcomes in a meta-analysis. But the presence of a positive ef-
fect for some outcomes supports the contention that action plans
can alter patient actions, as has been demonstrated with asthma
patients. Whether larger numbers of subjects contributing data to
healthcare outcomes will subsequently demonstrate small benefits
in resource utilisation remains to be seen. To find a statistically sig-
nificant difference between interventions for the mean differences
would require large increases in sample sizes. Power calculations
indicate the numbers required to show statistically significant dif-
ferences between group are: 160 for hospitalisation, 746 for emer-
gency visits to the GP and 1970 for emergency department visits.
However, there is further evidence to support the use of action
plans in COPD from a retrospective cohort study which identified
reduced hospitalisation with the use of an action plan (0.8/patient)
compared to a control group (1.3/patient) (Parenteau 2003).
The results from this review show that action plans provide an
approach to the management of acute exacerbations of COPD
which increases patients self-efficacy and their use of oral antibi-
otics and corticosteroids. To date this has not shown any signif-
icant reduction in the use of healthcare resources, change in the
participants physiology or improved clinical outcomes. While the
lack of evidence to support the role of the action plan in COPD
management should not be necessarily seen as the evidence of lack
of efficacy, at this time a written action plan without a broader self-
management plan cannot be recommended for widespread adop-
tion in primary care.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
The data included in this review shows that the use of action plans
aids the COPD patient to recognise and respond to their exacer-
bations through the self-initiation of medication. The data in this
review is not sufficient, however, to draw clinical recommenda-
tions regarding the use of action plans in COPD, as the number
of studies and variability in published outcomes does not demon-
strate any significant change in clinical outcomes or use of health-
care resources.
Implications for research
This review highlights the need for continued research into the
use of action plans in COPD, to increase the number of studies
and study participants in outcomes so that the evidence can either
show benefit or provide evidence of no effect. The action plan may
need to be refined for optimal use by COPD patients.
P O T E N T I A L C O N F L I C T O F
I N T E R E S T
One reviewer (RWB) was an investigator in an included study
(McGlone 2004).
A C K N O W L E D G E M E N T S
Toby Lasserson- helped with the overall construction of the review
Chris Cates- shared with us his statistical knowledge
The following people conversed with us over articles for inclu-
sion, exclusion, and those still in progress- Elizabeth Arnold, Jean
Bourbeau, Michael Epton, Robyn Maguigan, Samantha Prigmore,
Harry Rea, Ian Town, Paul Watson, John Wellingham
S O U R C E S O F S U P P O R T
External sources of support
• Commonwealth Department of Health and Aging AUS-
TRALIA
Internal sources of support
• University of Tasmania AUSTRALIA
R E F E R E N C E S
References to studies included in this review
McGeoch 2004 {unpublished data only}
McGeoch GR, Willsman KJ, Dowson CA, Town GI, Frampton CM,
McCartin FJ, et al. Self-management plans in the primary care of
patients with COPD.
McGlone 2004 {unpublished data only}∗ McGlone S, Wood-Baker R, Walters EH. The effect of a written
action plan in COPD [Abstract]. Respirology 2004;9(2 Suppl):A46.
Watson 1997 {published data only}∗ Watson PB, Town GI, Holbrook N, Dwan C, Toop LJ, Drennan
CJ. Evaluation of a self-managment plan for chronic obstructive pul-
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Bourbeau J, Nault D, Dang-Tan T. Self-management and behaviour
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271–7.
Dhein 2003
Dhein Y, Munks-Lederer C, Worth H. Evaluation of a structured
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9Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
conditions - a pilot study. Medizinische Klinik 2003;57:591–7.
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JA. Early therapy improves outcomes of exacerbations of chronic ob-
structive pulmonary disease. American Journal of Respiratory & Crit-
ical Care Medicine 2004;169:1298–303.
Wood-Baker 2003
Wood-Baker R, Walters E, Gibson P. Oral corticosteroids for acute
exacerbations of chronic obstructive pulmonary disease (Cochrane
review). In: The Cochrane Database of Systematic Reviews, 3, 2003.
Worth 2002
Worth H. Effects of patient education in asthma and COPD - what
is provable?. Medizinische Klinik 2002;97(Suppl 2):20–24.
Worth 2004
Worth H, Dhein Y. Does patient education modify behaviour in the
management of COPD?. Medizinische Klinik 2004;52:267–70.
∗Indicates the major publication for the study
T A B L E S
Characteristics of included studies
Study McGeoch 2004
Methods Trial type: RCT
Control: usual care
Blinding: nil
Dropouts/Crossovers: Intervention=1death, 1 withdrew consent; control=2 deaths, 2 wtihdrew consent, 1
unable to be contacted
Co-interventions:
Duration of use: 12 months
Participants Diagnosis: COPD according to ATS criteria (history of cough, sputum, SOB, >10y pack smoking); plus
FEV1/FVC<70%, weekly symptoms, history or 1+ exacerbations in previous 12 months requiring increase
in therapy.
No. eligible: 257 screened
No. Randomised: 159
No. Completed: 152
Age: int 69.8(11.6); control 72.1(9.9)
Male:Female: M 52% int; 67% cont
COPD severity: Moderate
Smoking history: >10 pack years
11Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of included studies (Continued )
Recruitment Centre: GP practices, also searched prescription databases for bronchodilator and inhaled
corticosteroid prescriptions to increase number patients screened.
Major exclusions: Unable/unwilling to sign consent, primary diagnosis asthma, other primary functionally
limiting disease, other medical condition likely to affect patient mortality, hospital level residential care,
already using self-management plan, on domicillary O2, attending GP that already uses self-managment plans
more than occasionally, exacerbation of COPD requiring increased treatment within 6 weeks or admission to
general hospital within 3 months, cognitive impairment as per 3MS of <75%, alpha1 antitrypsin deficiency.
Interventions Description AP intervention: usual care, and individual standardised education session from practice nurse
or respiratory educator on the use of a self-management plan which includes methods of early recognition
of exacerbations and appropriate self-initiated interventions including antibiotics and short-course oral cor-
ticosteroids; instruction to make early contact with GP
Description Control: Usual care, specifically denied access to written self-management plan.
Number interventions:84
Number controls: 73
Outcomes Length of times followed up: 12 months
Year study performed: July 2002-Dec 2003
Medications: % people used courses of antibiotics and oral steroids at 6 and 12 months
HRQoL: SGRQ measured at 6 and 12 months
Helathcrae utilisation: % of participants who attended GP visits, ED visits, and hospital admissions at 6 and
12 months
% who took courses of antibiotics/prednisone at 12 months
Hospital Anxiety and Depression Scale (HADS)
COPD-SMI at 12 months
Notes Note no method of randomisation and no details of allocation concealment are given.
Non-standard education on smoking cessation, exercise, controlling breathlessness, nutrition, use of inhaled
therapy and immunisation were given according to practice standards
Allocation concealment B – Unclear
Study McGlone 2004
Methods Trial type: RCT
Control: routine care, specifically denied AP
Blinding:
Dropouts/Crossovers: Intervention group: 5 deaths; 8 withdrawals. Control Group: 4 deaths; 8 withdrawals;
2 lost to follow-up.
Co-interventions:
Duration of use: 54 in intervention group and 58 in control group completed 12 months.
Participants Diagnosis:COPD as primary functionally limiting illness, aged >50yo, tobacco smoking history >10pack
years, and either a FEV1<65% and/or a FEV1/FVC<70%
No.eligible:262
No. Randomised: 139
No. completed: 112
Age: Intervention 69+/-7.8; Control 71+/-8.4 years
Male:Female: Intervention 49 males, 18 female; control 67 males, 5 females
COPD severity: Intervention FEV1%pred 46.3+/-16, FEV1/FVC 56.8+/-15.7; Control FEV1% pred 44.2+
/-15.8, FEV1/FVC 50.9+/-12.2
Smoking history: Intervention 55+/-26 pack years; control 59+/-33.7pack years. 1 intervention and 2 controls
ceased smoking during study. 2 in intervention group recommenced.
Recruitment centre: All GPs registered with Southern Tasmanian Divisio nof General Practitioners (n=255)
contacted and invited to participate.
Major exclusions: Nursing home residents.
12Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of included studies (Continued )
Intervention characteristics: n=67: Age 69+/-7.8; 49 males; 46 married, 37 widowed; 12 separated/divorced;
5 never married; 40 labourers; 19 clerical, sales and service industry workers; 16 tradespersons; 11 managers,
admin and professional workers; 9 production and transport; 5 never worked; 36 current smokers; 55+/-26
pack year smoking history; BMI 25.9+/-5.8;
Control characteristics: n=72: Age 71+/-8.4; 67 males; 51 married, 33 widowed; 10 separated/divorced; 6
never married; 27 labourers; 28 clerical, sales and service industry workers; 27 tradespersons; 11 managers,
admin and professional workers; 7 production and transport; 0 never worked; 22 current smokers; 59+/-33.7
pack year smoking history; BMI 25.2+/-5.4;
Intervention Group: FEV1=1.1+/-0.5; FEV1% pred= 46.3+/-16; FEV1/FVC= 56.8+/-15.7; Daily steps 4751
(IQR 4473); SGRQ symptoms-59.9+/-22.7, activity-62.3+/-25.2, impacts 33.4+/-21.3, total 46.5+/-20.4;
Participation in pulmonary rehab 30; medications prescribed at enrolment: SABA 97, LABA 36, ipratropim
67, methylxanthine 8, inhaled corticosteroid 60, oral corticosteroid 8, O2 10.
Control group: FEV1=1.1+/-0.4; FEV1% pred=44.2+/-15.8 ; FEV1/FVC=50.9+/-12.2 ; Daily steps
3454(IQR=3041); SGRQ symptoms-62.7+/-20.6, activity-66.4+/-20.2, impacts 32.1+/-17.3, total 47.3+
/-16.6; Participation in pulmonary rehab 24; medications prescribed at enrolment: SABA 78, LABA 24,
ipratropim 57, methylxanthine 7, inhaled corticosteroid 43, oral corticosteroid 7, O2 4.
Interventions Description AP intervention: COPD info booklet and individual educational session with resp nurse (covered
basic COPD pathology, smoking cessation, immunisations, nutrition, exercise, clearing mucus from lungs,
controlling breathlessness during ADLs, stress management, medications, correct use of inhalers and contact
details of community support services). Also written self-management plan listing maintenance medications
and individual AP based on early recognition of exacerbations. 76% patients got instructions to start short
course oral corticosteroids and an antibiotic; remaining 24% received instructions to initiate antibiotics only
(n=10), double dose inhaled corticosteroids and start antibiotic (2), initiate short course oral corticosteroids
only(1), or contact GP(3). Prescriptions were provided as necessary. All were encouraged to present to GP
early during exacerbation.
Description control: Usual care, specifically denied action plan
Number interventions: 54
Number controls: 58
Outcomes Length of times followed up: 3, 6, 9, 12 months, 6 and 12 at GP, 3 and 9 using standard telephone interviews
Year study performed: 2002
No. exacerbation:
Medications: diary to record antibiotic use, short course corticosteroidsused
HRQoL: change score SGRQ at 6 and 12 months
Healthcare utilisation:diary used to record GP consults, hospitalisations and attendences to ER
Lung Function:
Functional capacity: physical activity assessed at baseline, 6 and 12 months using digital pedometer.
Symptom scores:
Mortality:
Days lost from work:
Notes
Allocation concealment B – Unclear
Study Watson 1997
Methods Trial type: RCT
Control: usual care; specifically denied access to AP and booklet
Blinding: nil
Dropouts/Crossovers: 13: 4 offended by questionnaire; 3 experienced complications from concurrent medical
problems; 3 felt study protocol too demanding; 1 left country;2 died.
Co-interventions: usual care
Duration of use: 6 months
13Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of included studies (Continued )
Participants Diagnosis: COPD defined according to American Thoracic Society: diagnosis of COPD as major function-
ally limiting disease; smoking history >10 pack-years; FEV1<65%;FEV1/FVC<70%; current use of bron-
chodilator therapy.
No.eligible: 93 patients screened for possible inclusion; 24 did not meet inclusion criteria so 69 enrolled
No. Randomised: 69 enrolled
No. completed: 56
Age: mean age 68 years
Male:Female: 62% male
COPD severity:
Smoking history: must’ve had 10 pack-year history
Recruitment centre: 12 practices involving 22 GPs
Major exclusions: Primary diagnosis of asthma (onset<35yo), primary diagnosis of cardiac disease (uncon-
trolled heart failure); primary or secondary diagnosis of another functionally limiting disease (except cor
pulmonale) that could signif affect patient mortality within 6 months of entry to the study (malignant neo-
plasm) or participation in the study (psychoses); continuous use of oral corticosteroid; long-term antibiotic
therapy; and rest-home residents.
Intervention characteristics: Age 68(10);Male 62%;married52%; current smoker24%; FEV%pred 37(14);
access to nebulizer 17%; own a peak flow meter 76%; influenza vaccine in last year 72%
Control characteristics: Age 67(8), male67%; maried37%; current smoker33%; FEV1%pred 36(16); access
to nebulizer 26%; own a peak flow meter 70%; influenza vaccine in last year 44%
Intervention Group: Days in study:186(13); days recorded on symptom diary144(62); breathing recorded
as usual 56%(37);mild18%(19); moderate17%(24); severe 8(21); days on antibiotics 10(11); days on pred-
nisolone 15(22); visits to GP or PN 3(3)
Control group: Days in study:187(7); Days recorded on symptom diary 160(51); Breathing recorded as usual
51%(37);mild 21%(24); moderate 20%(26); severe 8(13); days on antibiotics 4(6); days on prednisolone
9(22); visits to GP or PN 2(3)
Interventions Description AP intervention: advice on management of usual care and exacerbations, and a booklet on
self-management; supply of prednisone and antibiotic from GP. Booklet ’A guide to living positively with
COPD’ was developed and circulated among patients GPs and family. Covered smoking cessation, controlling
breathlessness, exercise, daily activities, diet, sleep, clearin mucus, planning for future, medications, O2 and
contact details for support services
Description control: usual care
Number interventions:29
Number controls: 27
Outcomes Length of times followed up: 6 months
Year study performed: 1994
HRQoL: Used absolute SRGQ
Healthcare utilisation:
Lung Function:
Functional capacity:
Symptom scores:
Mortality:
Days lost from work:
Days on antibiotics/prednisone
Notes
Allocation concealment B – Unclear
Characteristics of excluded studies
Bourbeau 2004 Was not possible to extract outcome data in regard to AP only.
Dhein 2003 Not RCT.
14Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of excluded studies (Continued )
Parenteau 2003 Not RCT.
Worth 2004 Was not possible to extract outcome data in regard to AP only.
Characteristics of ongoing studies
Study Brightling
Trial name or title Self-management in chronic obstructive pulmonary disease: an approach to reduce the need for hospital ad-
mission.
Participants
Interventions
Outcomes
Starting date Jan 8 2001
Contact information research@lri.org.uk
Notes No reply received when contacted
Study Prigmore 2001
Trial name or title Does an individualised self-management plan help patients with chronic obstructive pulmonary disease (COPD
initiate early treatment for infective exacerbations?
Participants 40-20; diagnosis of COPD attending the nurse-led clinic at St.George’s Helathcare NHS Trust
Interventions Education, issuing of a self-management leaflet, symptom card and a prescription for antibiotics and cortico-
steroids
Outcomes See if individualised self-management plan improves patients ability to recognised early signs of an infection
and self initiate treatment during an exacerbation.
Starting date Jan 1 2004
Contact information Ms Samantha Prigmore
Chest Medicine
St George’s Hospital Medical School
Blackshaw Road
Tooting
London
SW17 0RE UK
Samantha.prigmore@stgeorges.nhs.uk
Notes To be completed end of September 2004
Study Sweeney 2002
Trial name or title COPD - education & self-management intervention
Participants 20; from Chest Clinic
Interventions 30 minute education and issuing of a self-management plan
Outcomes Measured via COPD self efficacy questionairre, 15 MCQs on knowledge of self-management plan; questionnaire
on views of self-management plan; group discussion of self-management plan.
Starting date Nov 30 2002
Contact information Pam Sweeney
Outreach Service
Birmingham Heartlands & Solihull NHS Trust (Teaching)
Bordesley Green Road
15Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of ongoing studies (Continued )
Bordesley Green East Birmingham
B9 5SS’
UK
Ph: 01214240186
email: Pamela.Sweeney@heartsol.wmids.nhs.uk
Notes No reply received when contacted
Study Wellingham 2002
Trial name or title Reducing hospital demand through a single chronic disease management programme for COPD and associated
co-morbidity [Abstract]
Participants 138
Interventions
Outcomes dyspnoea rating, spirometry, shuttle walk test, SF-36, and chronic respiratory questionnaire
Starting date June 2002
Contact information JWellingham@CMDHB.org.nz
Notes Definitive article to be published in Internal Medicine Journal, hopefully in Sept/Oct 2004.
A N A L Y S E S
Comparison 01. Action Plan versus usual care
Outcome titleNo. of
studies
No. of
participants Statistical method Effect size
01 Number of admissions to
hospital in 12 months
2 WMD (Fixed) 95% CI 0.16 [-0.09, 0.42]
02 Visits to GP/PN in 6 months 1 56 Weighted Mean Difference (Fixed) 95% CI 1.00 [-0.57, 2.57]
03 Number scheduled GP visits in
12 months
1 Mean Difference (Fixed) 95% CI -0.50 [-4.06, 3.06]
04 Number emergency visits to
GP for COPD in 12 months
1 Mean difference (Fixed) 95% CI -0.20 [-1.55, 1.15]
05 Number of total GP visits in
12 months
1 Mean difference (Fixed) 95% CI 0.07 [-0.28, 0.43]
06 Number of times treated in the
emergency department in 12
months
2 WMD (Fixed) 95% CI -0.01 [-0.12, 0.10]
07 Days on Antibiotics in 6
months
1 56 Weighted Mean Difference (Fixed) 95% CI 6.00 [1.40, 10.60]
08 Days on corticosteroids in 6
months
1 56 Weighted Mean Difference (Fixed) 95% CI 6.00 [-5.53, 17.53]
09 Patients initiating antibiotics in
6 months
1 56 Odds Ratio (Fixed) 95% CI 10.16 [2.02, 51.09]
10 Patients initiating steroids in 6
months
1 56 Odds Ratio (Fixed) 95% CI 6.58 [1.29, 33.62]
11 Courses of Antibiotics in 12
months
2 WMD (Fixed) 95% CI 0.14 [-0.20, 0.48]
12 Courses of oral corticosteroids
in 12 months
2 WMD (Fixed) 95% CI 0.35 [-0.17, 0.88]
16Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
13 Number of subjects with >=
1 exacerbation COPD with
antibiotics in 12 months
1 139 Peto Odds Ratio 95% CI 2.44 [1.14, 5.23]
14 Length of exacerbations 0 0 Weighted Mean Difference (Fixed) 95% CI Not estimable
15 SGRQ symptom scores at 6
months
2 WMD (Fixed) 95% CI -4.78 [-10.81, 1.24]
16 SGRQ activity scores at 6
months
2 WMD (Fixed) 95% CI -2.43 [-7.37, 2.50]
17 SGRQ impact scores at 6
months
2 WMD (Fixed) 95% CI -0.62 [-4.45, 3.21]
18 SGRQ total scores at 6 months 2 WMD (Fixed) 95% CI -1.91 [-5.46, 1.63]
19 SGRQ symptom scores at 12
months
2 WMD (Fixed) 95% CI 1.87 [-3.27, 7.00]
20 SGRQ activity scores at 12
months
2 WMD (Fixed) 95% CI -2.82 [-6.84, 1.19]
21 SGRQ impact scores at 12
months
2 WMD (Fixed) 95% CI 1.16 [-2.21, 4.53]
22 SGRQ total scores at 12
months
2 WMD (Fixed) 95% CI -0.32 [-3.34, 2.70]
23 FEV1 (mls) at 6 months 1 Mean difference (Fixed) 95% CI 50.00 [-29.86,
129.86]
24 FEV1 (mls) at 12 months 1 Mean difference (Fixed) 95% CI 43.00 [-63.30,
149.30]
25 FEV1 % predicted at 6 months 2 WMD (Fixed) 95% CI 1.83 [-1.05, 4.71]
26 FEV1 % predicted at 12
months
1 Mean difference (Fixed) 95% CI 2.00 [-1.89, 5.89]
27 FEV1/FVC at 6 months 1 Mean difference (Fixed) 95% CI -0.50 [-3.99, 2.99]
28 FEV1/FVC at 12 months 1 Mean difference (Fixed) 95% CI -0.30 [-4.50, 3.90]
29 Functional Capacity 0 0 Weighted Mean Difference (Fixed) 95% CI Not estimable
30 Number of days symptoms
recorded in 6 months
1 56 Weighted Mean Difference (Fixed) 95% CI -16.00 [-45.65,
13.65]
31 Days of breathing recorded as
usual in 6 months
1 56 Weighted Mean Difference (Fixed) 95% CI 5.00 [-14.39, 24.39]
32 Days of breathing recorded as
mild in 6 months
1 56 Weighted Mean Difference (Fixed) 95% CI -3.00 [-14.39, 8.39]
33 Days of breathing recorded as
moderate in 6 months
1 56 Weighted Mean Difference (Fixed) 95% CI -3.00 [-16.13,
10.13]
34 Days of breathing recorded as
severe in 6 months
1 56 Weighted Mean Difference (Fixed) 95% CI 0.00 [-9.08, 9.08]
35 Mortality 2 298 Peto Odds Ratio 95% CI 1.01 [0.32, 3.24]
36 Days lost from work 0 0 Weighted Mean Difference (Fixed) 95% CI Not estimable
37 HADS anxiety 1 Mean difference (Fixed) 95% CI 0.14 [-1.66, 1.94]
38 HADS depression 1 Mean difference (Fixed) 95% CI 0.25 [-0.59, 1.09]
39 SMI well knowledge 1 Mean difference (Fixed) 95% CI 1.10 [0.46, 1.74]
40 SMI well actions 1 Mean difference (Fixed) 95% CI 0.50 [0.21, 0.79]
41 SMI early exacerbation
knowledge
1 Mean difference (Fixed) 95% CI 1.80 [0.75, 2.85]
42 SMI early exacerbation actions 1 Mean difference (Fixed) 95% CI 2.30 [0.96, 3.64]
43 SMI severe exacerbation
knowledge
1 Mean difference (Fixed) 95% CI 2.50 [1.04, 3.96]
44 SMI severe exacerbation actions 1 Mean difference (Fixed) 95% CI 1.50 [0.62, 2.38]
17Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
I N D E X T E R M S
Medical Subject Headings (MeSH)
Behavior Therapy; Health Promotion; Patient Care Planning; ∗Patient Education; Pulmonary Disease, Chronic Obstructive [∗therapy];
Randomized Controlled Trials; Recurrence; ∗Self Care
MeSH check words
Humans
C O V E R S H E E T
Title Action plans for chronic obstructive pulmonary disease
Authors Turnock AC, Walters EH, Walters JAE, Wood-Baker R
Contribution of author(s) A. Turnock:
Screened search results against inclusion criteria
Data management for the review
Grading of reviews
Data extraction
Analysis of data
Writing review
Updating review
J. Walters:
Grading of reviews
Data extraction
Advice on search strategy, data extraction and meta-analysis
Revision of review drafts
R. Wood-Baker:
Formulated review topic
Advice on search strategy, data extraction and meta-analysis
Revision of review drafts
E. Walters:
Editing protocol and review
Issue protocol first published 2004/3
Review first published 2005/4
Date of most recent amendment 25 August 2005
Date of most recent
SUBSTANTIVE amendment
23 July 2005
What’s New Information not supplied by author
Date new studies sought but
none found
Information not supplied by author
Date new studies found but not
yet included/excluded
Information not supplied by author
Date new studies found and
included/excluded
01 August 2004
Date authors’ conclusions
section amended
Information not supplied by author
Contact address Miss Allison Turnock
18Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Medical Student
Discipline of Medicine
University of Tasmania Medical School
Discipline of Medicine, University of Tasmania
43 Collins Street
Hobart
Tasmania
7001
AUSTRALIA
E-mail: aturnock@utas.edu.au
DOI 10.1002/14651858.CD005074.pub2
Cochrane Library number CD005074
Editorial group Cochrane Airways Group
Editorial group code HM-AIRWAYS
G R A P H S A N D O T H E R T A B L E S
Analysis 01.01. Comparison 01 Action Plan versus usual care, Outcome 01 Number of admissions to hospital
in 12 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 01 Number of admissions to hospital in 12 months
Study WMD (SE) WMD (Fixed) Weight WMD (Fixed)
95% CI (%) 95% CI
McGeoch 2004 -0.02 (0.32) 16.5 -0.02 [ -0.65, 0.61 ]
McGlone 2004 0.20 (0.14) 83.5 0.20 [ -0.08, 0.48 ]
Total (95% CI) 100.0 0.16 [ -0.09, 0.42 ]
Test for heterogeneity chi-square=0.38 df=1 p=0.54 I?? =0.0%
Test for overall effect z=1.26 p=0.2
-1.0 -0.5 0 0.5 1.0
Favours Action Plan Favours Usual Care
19Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.02. Comparison 01 Action Plan versus usual care, Outcome 02 Visits to GP/PN in 6 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 02 Visits to GP/PN in 6 months
Study Action Plan Usual Care Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Watson 1997 29 3.00 (3.00) 27 2.00 (3.00) 100.0 1.00 [ -0.57, 2.57 ]
Total (95% CI) 29 27 100.0 1.00 [ -0.57, 2.57 ]
Test for heterogeneity: not applicable
Test for overall effect z=1.25 p=0.2
-4.0 -2.0 0 2.0 4.0
Favours Action Plan Favours Usual Care
Analysis 01.03. Comparison 01 Action Plan versus usual care, Outcome 03 Number scheduled GP visits in 12
months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 03 Number scheduled GP visits in 12 months
Study Mean Difference (SE) Mean Difference (Fixed) Weight Mean Difference (Fixed)
95% CI (%) 95% CI
McGlone 2004 -0.50 (1.82) 100.0 -0.50 [ -4.06, 3.06 ]
Total (95% CI) 100.0 -0.50 [ -4.06, 3.06 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.28 p=0.8
-10.0 -5.0 0 5.0 10.0
Favours Action Plans Favours Usual Care
Analysis 01.04. Comparison 01 Action Plan versus usual care, Outcome 04 Number emergency visits to GP
for COPD in 12 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 04 Number emergency visits to GP for COPD in 12 months
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGlone 2004 -0.20 (0.69) 100.0 -0.20 [ -1.55, 1.15 ]
Total (95% CI) 100.0 -0.20 [ -1.55, 1.15 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.29 p=0.8
-4.0 -2.0 0 2.0 4.0
Favours Action Plan Favours Usual Care
20Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.05. Comparison 01 Action Plan versus usual care, Outcome 05 Number of total GP visits in 12
months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 05 Number of total GP visits in 12 months
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGeoch 2004 0.07 (0.18) 100.0 0.07 [ -0.28, 0.43 ]
Total (95% CI) 100.0 0.07 [ -0.28, 0.43 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.40 p=0.7
-1.0 -0.5 0 0.5 1.0
Favours Action Plan Favours Usual Care
Analysis 01.06. Comparison 01 Action Plan versus usual care, Outcome 06 Number of times treated in the
emergency department in 12 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 06 Number of times treated in the emergency department in 12 months
Study WMD (SE) WMD (Fixed) Weight WMD (Fixed)
95% CI (%) 95% CI
McGeoch 2004 -0.25 (0.27) 4.2 -0.25 [ -0.77, 0.28 ]
McGlone 2004 0.00 (0.06) 95.8 0.00 [ -0.11, 0.11 ]
Total (95% CI) 100.0 -0.01 [ -0.12, 0.10 ]
Test for heterogeneity chi-square=0.82 df=1 p=0.37 I?? =0.0%
Test for overall effect z=0.19 p=0.8
-1.0 -0.5 0 0.5 1.0
Favours Action Plan Favours Usual Care
Analysis 01.07. Comparison 01 Action Plan versus usual care, Outcome 07 Days on Antibiotics in 6 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 07 Days on Antibiotics in 6 months
Study Action Plan Usual Care Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Watson 1997 29 10.00 (11.00) 27 4.00 (6.00) 100.0 6.00 [ 1.40, 10.60 ]
Total (95% CI) 29 27 100.0 6.00 [ 1.40, 10.60 ]
Test for heterogeneity: not applicable
Test for overall effect z=2.56 p=0.01
-10.0 -5.0 0 5.0 10.0
Favours Usual Care Favours Action Plan
21Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.08. Comparison 01 Action Plan versus usual care, Outcome 08 Days on corticosteroids in 6
months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 08 Days on corticosteroids in 6 months
Study Action Plan Usual Care Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Watson 1997 29 15.00 (22.00) 27 9.00 (22.00) 100.0 6.00 [ -5.53, 17.53 ]
Total (95% CI) 29 27 100.0 6.00 [ -5.53, 17.53 ]
Test for heterogeneity: not applicable
Test for overall effect z=1.02 p=0.3
-100.0 -50.0 0 50.0 100.0
Favours Usual Care Favours Action Plan
Analysis 01.09. Comparison 01 Action Plan versus usual care, Outcome 09 Patients initiating antibiotics in 6
months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 09 Patients initiating antibiotics in 6 months
Study Action Plan Usual Care Odds Ratio (Fixed) Weight Odds Ratio (Fixed)
n/N n/N 95% CI (%) 95% CI
Watson 1997 13/29 2/27 100.0 10.16 [ 2.02, 51.09 ]
Total (95% CI) 29 27 100.0 10.16 [ 2.02, 51.09 ]
Total events: 13 (Action Plan), 2 (Usual Care)
Test for heterogeneity: not applicable
Test for overall effect z=2.81 p=0.005
0.01 0.1 1 10 100
Favours Usual Care Favours Action Plan
22Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.10. Comparison 01 Action Plan versus usual care, Outcome 10 Patients initiating steroids in 6
months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 10 Patients initiating steroids in 6 months
Study Action Plan Usual Care Odds Ratio (Fixed) Weight Odds Ratio (Fixed)
n/N n/N 95% CI (%) 95% CI
Watson 1997 10/29 2/27 100.0 6.58 [ 1.29, 33.62 ]
Total (95% CI) 29 27 100.0 6.58 [ 1.29, 33.62 ]
Total events: 10 (Action Plan), 2 (Usual Care)
Test for heterogeneity: not applicable
Test for overall effect z=2.26 p=0.02
0.01 0.1 1 10 100
Favours Usual Care Favours Action Plan
Analysis 01.11. Comparison 01 Action Plan versus usual care, Outcome 11 Courses of Antibiotics in 12
months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 11 Courses of Antibiotics in 12 months
Study WMD (SE) WMD (Fixed) Weight WMD (Fixed)
95% CI (%) 95% CI
McGeoch 2004 0.13 (0.18) 94.8 0.13 [ -0.22, 0.48 ]
McGlone 2004 0.40 (0.76) 5.2 0.40 [ -1.09, 1.89 ]
Total (95% CI) 100.0 0.14 [ -0.20, 0.48 ]
Test for heterogeneity chi-square=0.12 df=1 p=0.73 I?? =0.0%
Test for overall effect z=0.82 p=0.4
-1.0 -0.5 0 0.5 1.0
Favours Usual Care Favours Action Plan
23Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.12. Comparison 01 Action Plan versus usual care, Outcome 12 Courses of oral corticosteroids in
12 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 12 Courses of oral corticosteroids in 12 months
Study WMD (SE) WMD (Fixed) Weight WMD (Fixed)
95% CI (%) 95% CI
McGeoch 2004 0.13 (0.37) 52.4 0.13 [ -0.59, 0.86 ]
McGlone 2004 0.60 (0.39) 47.6 0.60 [ -0.16, 1.36 ]
Total (95% CI) 100.0 0.35 [ -0.17, 0.88 ]
Test for heterogeneity chi-square=0.76 df=1 p=0.38 I?? =0.0%
Test for overall effect z=1.33 p=0.2
-1.0 -0.5 0 0.5 1.0
Favours Usual Care Favours Action Plan
Analysis 01.13. Comparison 01 Action Plan versus usual care, Outcome 13 Number of subjects with >= 1
exacerbation COPD with antibiotics in 12 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 13 Number of subjects with >= 1 exacerbation COPD with antibiotics in 12 months
Study Action plan Usual care Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N 95% CI (%) 95% CI
McGlone 2004 56/67 48/72 100.0 2.44 [ 1.14, 5.23 ]
Total (95% CI) 67 72 100.0 2.44 [ 1.14, 5.23 ]
Total events: 56 (Action plan), 48 (Usual care)
Test for heterogeneity: not applicable
Test for overall effect z=2.29 p=0.02
0.1 0.2 0.5 1 2 5 10
Favours usual care Favours action plan
24Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.14. Comparison 01 Action Plan versus usual care, Outcome 14 Length of exacerbations
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 14 Length of exacerbations
Study Treatment Control Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)
N
Mean(SD) N
Mean(SD) 95% CI (%) 95% CI
Total (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
-10.0 -5.0 0 5.0 10.0
Favours treatment Favours control
Analysis 01.15. Comparison 01 Action Plan versus usual care, Outcome 15 SGRQ symptom scores at 6
months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 15 SGRQ symptom scores at 6 months
Study WMD (SE) WMD (Fixed) Weight WMD (Fixed)
95% CI (%) 95% CI
McGlone 2004 -6.40 (3.67) 70.0 -6.40 [ -13.60, 0.80 ]
Watson 1997 -1.00 (5.62) 30.0 -1.00 [ -12.01, 10.01 ]
Total (95% CI) 100.0 -4.78 [ -10.81, 1.24 ]
Test for heterogeneity chi-square=0.65 df=1 p=0.42 I?? =0.0%
Test for overall effect z=1.56 p=0.1
-100.0 -50.0 0 50.0 100.0
Favours Action Plan Favours Usual Care
25Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.16. Comparison 01 Action Plan versus usual care, Outcome 16 SGRQ activity scores at 6 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 16 SGRQ activity scores at 6 months
Study WMD (SE) WMD (Fixed) Weight WMD (Fixed)
95% CI (%) 95% CI
McGlone 2004 -3.20 (2.72) 85.3 -3.20 [ -8.54, 2.14 ]
Watson 1997 2.00 (6.56) 14.7 2.00 [ -10.85, 14.85 ]
Total (95% CI) 100.0 -2.43 [ -7.37, 2.50 ]
Test for heterogeneity chi-square=0.54 df=1 p=0.46 I?? =0.0%
Test for overall effect z=0.97 p=0.3
-100.0 -50.0 0 50.0 100.0
Favours Action Plan Favours Usual Care
Analysis 01.17. Comparison 01 Action Plan versus usual care, Outcome 17 SGRQ impact scores at 6 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 17 SGRQ impact scores at 6 months
Study WMD (SE) WMD (Fixed) Weight WMD (Fixed)
95% CI (%) 95% CI
McGlone 2004 -0.50 (2.24) 76.2 -0.50 [ -4.89, 3.89 ]
Watson 1997 -1.00 (4.01) 23.8 -1.00 [ -8.86, 6.86 ]
Total (95% CI) 100.0 -0.62 [ -4.45, 3.21 ]
Test for heterogeneity chi-square=0.01 df=1 p=0.91 I?? =0.0%
Test for overall effect z=0.32 p=0.8
-10.0 -5.0 0 5.0 10.0
Favours Action Plan Favours Usual Care
26Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.18. Comparison 01 Action Plan versus usual care, Outcome 18 SGRQ total scores at 6 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 18 SGRQ total scores at 6 months
Study WMD (SE) WMD (Fixed) Weight WMD (Fixed)
95% CI (%) 95% CI
McGlone 2004 -2.30 (1.98) 83.1 -2.30 [ -6.19, 1.59 ]
Watson 1997 0.00 (4.41) 16.9 0.00 [ -8.64, 8.64 ]
Total (95% CI) 100.0 -1.91 [ -5.46, 1.63 ]
Test for heterogeneity chi-square=0.23 df=1 p=0.63 I?? =0.0%
Test for overall effect z=1.06 p=0.3
-10.0 -5.0 0 5.0 10.0
Favours Action Plan Favours Usual Care
Analysis 01.19. Comparison 01 Action Plan versus usual care, Outcome 19 SGRQ symptom scores at 12
months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 19 SGRQ symptom scores at 12 months
Study WMD (SE) WMD (Fixed) Weight WMD (Fixed)
95% CI (%) 95% CI
McGeoch 2004 2.30 (3.48) 56.7 2.30 [ -4.52, 9.12 ]
McGlone 2004 1.30 (3.98) 43.3 1.30 [ -6.51, 9.11 ]
Total (95% CI) 100.0 1.87 [ -3.27, 7.00 ]
Test for heterogeneity chi-square=0.04 df=1 p=0.85 I?? =0.0%
Test for overall effect z=0.71 p=0.5
-10.0 -5.0 0 5.0 10.0
Favours Action Plan FavoursUsual Care
27Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.20. Comparison 01 Action Plan versus usual care, Outcome 20 SGRQ activity scores at 12 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 20 SGRQ activity scores at 12 months
Study WMD (SE) WMD (Fixed) Weight WMD (Fixed)
95% CI (%) 95% CI
McGeoch 2004 -2.02 (2.92) 49.2 -2.02 [ -7.74, 3.70 ]
McGlone 2004 -3.60 (2.87) 50.8 -3.60 [ -9.23, 2.03 ]
Total (95% CI) 100.0 -2.82 [ -6.84, 1.19 ]
Test for heterogeneity chi-square=0.15 df=1 p=0.70 I?? =0.0%
Test for overall effect z=1.38 p=0.2
-10.0 -5.0 0 5.0 10.0
Favours Action Plan Favours Usual Care
Analysis 01.21. Comparison 01 Action Plan versus usual care, Outcome 21 SGRQ impact scores at 12 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 21 SGRQ impact scores at 12 months
Study WMD (SE) WMD (Fixed) Weight WMD (Fixed)
95% CI (%) 95% CI
McGeoch 2004 3.30 (2.33) 54.5 3.30 [ -1.27, 7.87 ]
McGlone 2004 -1.40 (2.55) 45.5 -1.40 [ -6.40, 3.60 ]
Total (95% CI) 100.0 1.16 [ -2.21, 4.53 ]
Test for heterogeneity chi-square=1.85 df=1 p=0.17 I?? =46.0%
Test for overall effect z=0.68 p=0.5
-10.0 -5.0 0 5.0 10.0
Favours Action Plan Favours Usual Care
28Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.22. Comparison 01 Action Plan versus usual care, Outcome 22 SGRQ total scores at 12 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 22 SGRQ total scores at 12 months
Study WMD (SE) WMD (Fixed) Weight WMD (Fixed)
95% CI (%) 95% CI
McGeoch 2004 1.27 (2.26) 46.5 1.27 [ -3.16, 5.70 ]
McGlone 2004 -1.70 (2.11) 53.5 -1.70 [ -5.83, 2.43 ]
Total (95% CI) 100.0 -0.32 [ -3.34, 2.70 ]
Test for heterogeneity chi-square=0.92 df=1 p=0.34 I?? =0.0%
Test for overall effect z=0.21 p=0.8
-10.0 -5.0 0 5.0 10.0
Favours Action Plan Favours Usual Care
Analysis 01.23. Comparison 01 Action Plan versus usual care, Outcome 23 FEV1 (mls) at 6 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 23 FEV1 (mls) at 6 months
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGlone 2004 50.00 (40.74) 100.0 50.00 [ -29.86, 129.86 ]
Total (95% CI) 100.0 50.00 [ -29.86, 129.86 ]
Test for heterogeneity: not applicable
Test for overall effect z=1.23 p=0.2
-1000.0 -500.0 0 500.0 1000.0
Favours Usual Care Favours Action Plan
Analysis 01.24. Comparison 01 Action Plan versus usual care, Outcome 24 FEV1 (mls) at 12 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 24 FEV1 (mls) at 12 months
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGlone 2004 43.00 (54.23) 100.0 43.00 [ -63.30, 149.30 ]
Total (95% CI) 100.0 43.00 [ -63.30, 149.30 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.79 p=0.4
-1000.0 -500.0 0 500.0 1000.0
Favours Usual Care Favours Action Plan
29Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.25. Comparison 01 Action Plan versus usual care, Outcome 25 FEV1 % predicted at 6 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 25 FEV1 % predicted at 6 months
Study WMD (SE) WMD (Fixed) Weight WMD (Fixed)
95% CI (%) 95% CI
McGlone 2004 2.30 (1.59) 85.7 2.30 [ -0.81, 5.41 ]
Watson 1997 -1.00 (3.88) 14.3 -1.00 [ -8.61, 6.61 ]
Total (95% CI) 100.0 1.83 [ -1.05, 4.71 ]
Test for heterogeneity chi-square=0.62 df=1 p=0.43 I?? =0.0%
Test for overall effect z=1.24 p=0.2
-10.0 -5.0 0 5.0 10.0
Favours Usual Care Favours Action Plan
Analysis 01.26. Comparison 01 Action Plan versus usual care, Outcome 26 FEV1 % predicted at 12 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 26 FEV1 % predicted at 12 months
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGlone 2004 2.00 (1.98) 100.0 2.00 [ -1.89, 5.89 ]
Total (95% CI) 100.0 2.00 [ -1.89, 5.89 ]
Test for heterogeneity: not applicable
Test for overall effect z=1.01 p=0.3
-10.0 -5.0 0 5.0 10.0
Favours Usual Care Favours Action Plan
Analysis 01.27. Comparison 01 Action Plan versus usual care, Outcome 27 FEV1/FVC at 6 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 27 FEV1/FVC at 6 months
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGlone 2004 -0.50 (1.78) 100.0 -0.50 [ -3.99, 2.99 ]
Total (95% CI) 100.0 -0.50 [ -3.99, 2.99 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.28 p=0.8
-10.0 -5.0 0 5.0 10.0
Favours Action Plan Favours Usual Care
30Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.28. Comparison 01 Action Plan versus usual care, Outcome 28 FEV1/FVC at 12 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 28 FEV1/FVC at 12 months
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGlone 2004 -0.30 (2.14) 100.0 -0.30 [ -4.50, 3.90 ]
Total (95% CI) 100.0 -0.30 [ -4.50, 3.90 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.14 p=0.9
-10.0 -5.0 0 5.0 10.0
Favours Action Plan Favours Usual Care
Analysis 01.29. Comparison 01 Action Plan versus usual care, Outcome 29 Functional Capacity
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 29 Functional Capacity
Study Treatment Control Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)
N
Mean(SD) N
Mean(SD) 95% CI (%) 95% CI
Total (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
-10.0 -5.0 0 5.0 10.0
Favours Usual Care Favours Action Plan
Analysis 01.30. Comparison 01 Action Plan versus usual care, Outcome 30 Number of days symptoms
recorded in 6 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 30 Number of days symptoms recorded in 6 months
Study Action Plan Usual Care Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Watson 1997 29 144.00 (62.00) 27 160.00 (51.00) 100.0 -16.00 [ -45.65, 13.65 ]
Total (95% CI) 29 27 100.0 -16.00 [ -45.65, 13.65 ]
Test for heterogeneity: not applicable
Test for overall effect z=1.06 p=0.3
-100.0 -50.0 0 50.0 100.0
Favours Action Plan Favours Usual Care
31Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.31. Comparison 01 Action Plan versus usual care, Outcome 31 Days of breathing recorded as
usual in 6 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 31 Days of breathing recorded as usual in 6 months
Study Action Plan Usual Care Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Watson 1997 29 56.00 (37.00) 27 51.00 (37.00) 100.0 5.00 [ -14.39, 24.39 ]
Total (95% CI) 29 27 100.0 5.00 [ -14.39, 24.39 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.51 p=0.6
-100.0 -50.0 0 50.0 100.0
Favours Action Plan Favours Usual Care
Analysis 01.32. Comparison 01 Action Plan versus usual care, Outcome 32 Days of breathing recorded as
mild in 6 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 32 Days of breathing recorded as mild in 6 months
Study Action Plans Usual Care Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Watson 1997 29 18.00 (19.00) 27 21.00 (24.00) 100.0 -3.00 [ -14.39, 8.39 ]
Total (95% CI) 29 27 100.0 -3.00 [ -14.39, 8.39 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.52 p=0.6
-100.0 -50.0 0 50.0 100.0
Favours treatment Favours control
Analysis 01.33. Comparison 01 Action Plan versus usual care, Outcome 33 Days of breathing recorded as
moderate in 6 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 33 Days of breathing recorded as moderate in 6 months
Study Action Plans Usual Care Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Watson 1997 29 17.00 (24.00) 27 20.00 (26.00) 100.0 -3.00 [ -16.13, 10.13 ]
Total (95% CI) 29 27 100.0 -3.00 [ -16.13, 10.13 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.45 p=0.7
-100.0 -50.0 0 50.0 100.0
Favours Action Plans Favours Usual Care
32Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.34. Comparison 01 Action Plan versus usual care, Outcome 34 Days of breathing recorded as
severe in 6 months
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 34 Days of breathing recorded as severe in 6 months
Study Action Plan Usual Care Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Watson 1997 29 8.00 (21.00) 27 8.00 (13.00) 100.0 0.00 [ -9.08, 9.08 ]
Total (95% CI) 29 27 100.0 0.00 [ -9.08, 9.08 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.00 p=1
-100.0 -50.0 0 50.0 100.0
Favours Action Plan Favours Usual Care
Analysis 01.35. Comparison 01 Action Plan versus usual care, Outcome 35 Mortality
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 35 Mortality
Study Action Plan Usual Care Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N 95% CI (%) 95% CI
McGeoch 2004 1/86 2/73 25.8 0.43 [ 0.04, 4.22 ]
McGlone 2004 5/67 4/72 74.2 1.37 [ 0.36, 5.26 ]
Total (95% CI) 153 145 100.0 1.01 [ 0.32, 3.24 ]
Total events: 6 (Action Plan), 6 (Usual Care)
Test for heterogeneity chi-square=0.73 df=1 p=0.39 I?? =0.0%
Test for overall effect z=0.02 p=1
0.01 0.1 1 10 100
Favours Action Plan Favours Usual Care
33Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.36. Comparison 01 Action Plan versus usual care, Outcome 36 Days lost from work
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 36 Days lost from work
Study Treatment Control Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)
N
Mean(SD) N
Mean(SD) 95% CI (%) 95% CI
Total (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
-10.0 -5.0 0 5.0 10.0
Favours treatment Favours control
Analysis 01.37. Comparison 01 Action Plan versus usual care, Outcome 37 HADS anxiety
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 37 HADS anxiety
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGeoch 2004 0.14 (0.92) 100.0 0.14 [ -1.66, 1.94 ]
Total (95% CI) 100.0 0.14 [ -1.66, 1.94 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.15 p=0.9
-4.0 -2.0 0 2.0 4.0
Favours Action Plan Favours Usual Care
Analysis 01.38. Comparison 01 Action Plan versus usual care, Outcome 38 HADS depression
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 38 HADS depression
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGeoch 2004 0.25 (0.43) 100.0 0.25 [ -0.59, 1.09 ]
Total (95% CI) 100.0 0.25 [ -0.59, 1.09 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.58 p=0.6
-4.0 -2.0 0 2.0 4.0
Favours Action Plan Favours Usual Care
34Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.39. Comparison 01 Action Plan versus usual care, Outcome 39 SMI well knowledge
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 39 SMI well knowledge
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGeoch 2004 1.10 (0.33) 100.0 1.10 [ 0.46, 1.74 ]
Total (95% CI) 100.0 1.10 [ 0.46, 1.74 ]
Test for heterogeneity: not applicable
Test for overall effect z=3.37 p=0.0008
-4.0 -2.0 0 2.0 4.0
Favours Usual Favours Action Plan
Analysis 01.40. Comparison 01 Action Plan versus usual care, Outcome 40 SMI well actions
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 40 SMI well actions
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGeoch 2004 0.50 (0.15) 100.0 0.50 [ 0.21, 0.79 ]
Total (95% CI) 100.0 0.50 [ 0.21, 0.79 ]
Test for heterogeneity: not applicable
Test for overall effect z=3.38 p=0.0007
-1.0 -0.5 0 0.5 1.0
Favours Usual Care Favours Action Plans
Analysis 01.41. Comparison 01 Action Plan versus usual care, Outcome 41 SMI early exacerbation knowledge
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 41 SMI early exacerbation knowledge
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGeoch 2004 1.80 (0.54) 100.0 1.80 [ 0.75, 2.85 ]
Total (95% CI) 100.0 1.80 [ 0.75, 2.85 ]
Test for heterogeneity: not applicable
Test for overall effect z=3.36 p=0.0008
-4.0 -2.0 0 2.0 4.0
Favours Usual Care Favours Action Plan
35Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.42. Comparison 01 Action Plan versus usual care, Outcome 42 SMI early exacerbation actions
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 42 SMI early exacerbation actions
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGeoch 2004 2.30 (0.68) 100.0 2.30 [ 0.96, 3.64 ]
Total (95% CI) 100.0 2.30 [ 0.96, 3.64 ]
Test for heterogeneity: not applicable
Test for overall effect z=3.36 p=0.0008
-4.0 -2.0 0 2.0 4.0
Favours Usual Care Favours Action Plan
Analysis 01.43. Comparison 01 Action Plan versus usual care, Outcome 43 SMI severe exacerbation
knowledge
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 43 SMI severe exacerbation knowledge
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGeoch 2004 2.50 (0.74) 100.0 2.50 [ 1.04, 3.96 ]
Total (95% CI) 100.0 2.50 [ 1.04, 3.96 ]
Test for heterogeneity: not applicable
Test for overall effect z=3.36 p=0.0008
-4.0 -2.0 0 2.0 4.0
Favours Usual Care Favours Action Plan
Analysis 01.44. Comparison 01 Action Plan versus usual care, Outcome 44 SMI severe exacerbation actions
Review: Action plans for chronic obstructive pulmonary disease
Comparison: 01 Action Plan versus usual care
Outcome: 44 SMI severe exacerbation actions
Study Mean difference (SE) Mean difference (Fixed) Weight Mean difference (Fixed)
95% CI (%) 95% CI
McGeoch 2004 1.50 (0.45) 100.0 1.50 [ 0.62, 2.38 ]
Total (95% CI) 100.0 1.50 [ 0.62, 2.38 ]
Test for heterogeneity: not applicable
Test for overall effect z=3.34 p=0.0008
-4.0 -2.0 0 2.0 4.0
Favours Usual Care Favours Action Plan
36Action plans for chronic obstructive pulmonary disease (Review)
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
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