Moves to enshrine self-care as a central part of the NHS efficiency drive have suffered a serious blow after a US trial in COPD had to be halted early because of a spike in mortality in patients encouraged to manage their own condition.
Researchers found almost three times as many patients with COPD died in a group receiving an education programme and an action plan for identifying and treating exacerbations as among those receiving standard primary care.
Self-care has been identified by the Government’s QIPP efficiency programme as one part of a three-step approach to driving down hospital admissions, which is being rolled out to CCGs covering 30 million patients.
But the authors of the new study, published online by respected US journal Annals of Internal Medicine, warned the results suggested self-care would not be suitable for all COPD patients. A leading GP commissioner who has led a programme of integrated care for COPD said it was key patients encouraged to self-care had a ‘safety net’.
The study randomised 426 COPD patients to a ‘comprehensive care programme’ – including four individual educational sessions, one group sess-ion and an action plan for identification and treatment of exacerbations – or guideline-based primary care. Patients were over 40 years old and had been hospitalised for COPD during the previous 12 months, but had had no exacerbation in the previous four weeks.
There were 28 deaths from all causes in the self-care group, compared with 10 in controls. Ten deaths were ascribed to COPD, compared with three in controls – a 3.6-fold increase in risk. The self-care group was also 13% more likely to be hospitalised than controls.
Study leader Dr Vincent Fan, lecturer in critical care medicine at the University of Minnesota, said: ‘Whatever the reasons for the high mortality, our findings suggest self-management may not be appropriate for all subsets of patients with COPD.’
Dr Joe McGilligan, a GP in Redhill, Surrey, and chair of ESyDoc CCG, was shortlisted for an NAPC Vision Award last year for a COPD integrated care programme.
He told Pulse: ‘[Schemes] need to be set up so patients have the safety net of professionals when they need it. It’s about knowing who to call and when.’
Sir John Oldham, national clinical lead for QIPP at the Department of Health, said there was ‘substantial’ evidence that self-care done well was effective: ‘Their intervention increased self-efficacy, but not knowledge. It was therefore bound to fail. You can’t short-cut self-management, but done properly it works.’