Self-management and early detection of exacerbations in patients with COPD

Abstract

Exacerbations of COPD are a major global importance. They have a profound negative effect on patients, resulting in poor health status; they accelerate the progression of the disease; and account for a large proportion the increasing healthcare spending on COPD. Yet, controversies remain over the definition of exacerbations, how they should be monitored and their underlying mechanisms. Early recognition of exacerbations and prompt treatment (decreased treatment delay) have shown to ameliorate recovery while improving health-related quality of life and reducing the risk of hospital admission. This thesis deals with different aspects of exacerbations, i.e. definitions, self-management behaviour during periods of symptom-aggravation and potential methods to enhance early detection and treatment of such events. To answer our main research questions we performed two systematic reviews, and three prospective cohort studies including a multicenter randomized trial (ACZiE study). In summary the main conclusions and recommendations were: 1) There is insufficient evidence to distinguish ‘harmless’ subtypes of exacerbations not necessitating anticipation by patients or healthcare providers. For now, current practice guidelines, indicating prompt recognition and treatment of each exacerbation, should be followed. 2) An individualized action plan is a low-burden intervention, which accelerates exacerbation recovery, severity and impact of exacerbations on health status. 3) Action plans are clearly not single-moment paper interventions, but concerns an individually tailored and dynamic process of systematic updates and reinforcement. Effective implementation requires a designated case-manager and clear arrangements between patients and healthcare providers. 4) Although evidence for effectiveness of telemedicine interventions is still relatively scarce, partly due to high heterogeneity of interventions, it has shown to be feasible in patients with COPD. Current technological developments provide an almost infinite variety of flexible solutions to closely monitor patients’ health status and to provide remote self-management support. 5) Strategies to enhance early detection and prompt treatment of exacerbations should be individually tailored. The pivotal objective remains to change patient behaviour for better disease control, and adequate anticipation in the event of an exacerbation. However, for certain sub-populations of patients this might not be sufficient and additional treatment modalities (surveillance / monitoring) might be indicated or should be augmented (self-management support / reinforcement). Future research implications were: 1) Before concluding EXACT-PRO to be the new ‘golden standard’, prospective studies are needed to evaluate its diagnostic properties in assessing exacerbation onset, covering the heterogeneity of COPD and its exacerbations. In absence of a ‘golden standard’, future prospective trials should assess exacerbations using the modified Anthonisen algorithm, completed by event–based counts. 2) To ensure optimal validity of diary-based exacerbation assessment, at least five vital requirements should be met (general discussion). 3) In addition to the importance of exacerbation frequency, future trials evaluating effectiveness of new treatments should also include severity, duration and health status impact. 4) Future trials are needed to compare simple and more sophisticated (tele-)monitoring modalities. Evaluation of effectiveness should also include exacerbation-related outcome: frequency, severity, duration and treatment-delay.