FIG. 30:  In comparing the discordant results of the Rice study^[21] vs the Fan study,^[22] it appeared that although the results of the Fan study were negative for pulmonary rehabilitation, nonetheless the intervention was effective as far as the process was concerned. As outlined in this Figure, 87% of the intervention group completed all four individual sessions; case managers covered 77% to 89% of all educational items; case managers completed 89% of follow-up telephone contacts; 2.5 exacerbations per patient-year were treated with prednisone in the intervention group versus 2.1 in the usual care group, and that result was statistically significantly greater for the intervention group.

However, it was noted that for the 600 self-reported exacerbations in the 217 patients in the intervention group, calls were made to case managers in only 27 instances, although the enrollees had been instructed to call the case managers every time there was an exacerbation.  Time from onset of symptoms to prednisone treatment was 6.4 days in the intervention group and 7.7 days in the usual care group, a difference that was not statistically significant, and time to antibiotic treatment was 7 days in the intervention group and 6.8 days in the usual care group, again not statistically significantly different. 

The concept of self-management centering around an exacerbation action plan is early recognition and prompt treatment of the exacerbation, and this was not occurring in the Fan study.  The second essential element of a collaborative self-management plan is that once therapy is initiated, the patient must contact a healthcare provider for further instructions, but this was not being done in the Fan study. 

This shows how complex the process of self- management really is.  It has to be done correctly if it is to succeed, and perhaps if it is done incorrectly the result could be a detrimental effect.  So these comparison data are very important, and the ATS and ERS are pursuing further discussions on these findings and how to improve them; but as a result of this study, at this point we do not know which approach is the better.