Does self-management support increase the risk of mortality amongst patients with COPD? A systematic review of the evidence

Introduction Self-management support is recommended worldwide for patients with COPD, although interventions are heterogeneous and evidence of their effectiveness is inconsistent. A large RCT was stopped prematurely because of increased mortality among patients in the self-management arm. We undertook a broad, comprehensive systematic review to evaluate whether self-management support increases mortality. Methods RCTs were sought to May 2012: population: patients with COPD; intervention: any intervention including self-management components compared with usual care/control; outcome: all-cause mortality; duration: g24 weeks. Pooled estimates of hazard ratios were obtained from random effects meta-analysis. Results From 13477 records, 44 RCTs reported 447 deaths among 5522 patients. Trials varied in size (n=26 to n=743), intervention (from single components to integrated care) and generally had few events. Overall there was no clear evidence of a difference in mortality, although the point estimate favoured the self-management interventions (HR 0.90 (95%CI 0.74, 1.09)). Sub-group analyses among trials of patients with more severe disease, prior admissions (HR 0.93 (0.72, 1.19)) or provision of action plans (HR 0.89 (0.70, 1.12)) did not differ. However, interventions with the most scheduled contact with healthcare professionals (HCP) showed reduced mortality (HR 0.72 (0.55, 0.95)). I 2 =0% (no heterogeneity) for all results. Conclusion There is no evidence that self-management support increases mortality. Only the most supported interventions (eg disease/case management/home rehabilitation) with substantial scheduled contact with HCP may reduce mortality.