Background
Methods
Search strategy
PRISMS systematic meta-review | RECURSIVE systematic review | |
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Population | Adults/children with asthma, from all social and demographic settings. Multi-condition studies if asthma data reported. | Adults (≥18 years) with asthma (within a wider search of long-term conditions), excluding studies in the developing world. |
Intervention | Self-management support interventions. | Self-management support interventions. |
Comparator | Typically ‘usual care’ or less intense self-management interventions. | Typically ‘usual care’ or less intense self-management interventions. |
Outcomes | Unscheduled use of healthcare services (admissions, A&E attendances, unscheduled consultations), health outcomes (asthma control), quality of life, process outcomes (ownership of action plans, self-efficacy). | Healthcare utilisation with comprehensive measures of costs or major cost drivers (i.e. hospitalisation, A&E attendances), quality of life. |
Settings | Any healthcare setting. | Any healthcare setting. |
Study design | Systematic reviews of RCTs. RCTs published after the date of the last search in the included systematic reviews (see Additional file 2). | RCTs |
Dates | Initial database search: January 1993 (3 years before the publication of the earliest systematic review identified in scoping work) to July 2012. Manual and forward citations were completed in November 2012. Update search: March 2015. Pre-publication update January 2017. | Initial database search: inception to May 2012. Update search: September 2015. |
Databases | MEDLINE, EMBASE, CINAHL, PsycINFO, AMED, BNI, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and ISI Proceedings (Web of Science). | CENTRAL, CINAHL, EconLit, EMBASE, Health Economics Evaluations Database, MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, NHS Economic Evaluation Database, and the PsycINFO. |
Manual searching | Systematic Reviews, Health Education and Behaviour, Health Education Research, Journal of Behavioural Medicine, and Patient Education and Counseling. | Systematic Reviews. |
Forward citations | On all included systematic reviews. Bibliographies of eligible reviews. | None. |
In progress studies | Abstracts were used to identify recently published trials. | Abstracts were used to identify recently published trials. |
Other exclusions | Previous versions of updated reviews. Papers not published in English. | Not applicable. |
Identification of relevant papers
PRISMS systematic meta-review | RECURSIVE systematic review | |
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Title and abstract screening | Initial training. One reviewer selected studies for full-text screening. Quality check: Random sample of 10% checked independently by second reviewer. Agreement: 97% for the initial search and 99% for the update. Uncertainties resolved by discussion. | Initial training. One reviewer selected studies for full-text screening. Quality check: Random sample of 40% checked independently by second reviewer. Agreement: 87% for the initial search and 88% for the update. Uncertainties resolved by discussion. |
Full-text screening | Following training, one reviewer selected possibly relevant studies for inclusion. Quality check: Random sample of 10% checked independently by second reviewer. Agreement: 83%. Uncertainties resolved by discussion. | Following training, one reviewer selected possibly relevant studies for inclusion. Quality check: Random sample of 30% checked independently by second reviewer. Agreement: 85%. Uncertainties resolved by discussion. |
Quality assessment | Duplicate quality assessment using: R-AMSTAR [17] for systematic reviews (‘high-quality’ defined as ≥31), combined with size of the review (‘large’ defined as ≥1000 participants) to give star rating (1* to 3*). Cochrane Risk of Bias tool for RCTs [15]. Disagreements resolved by discussion. | Duplicate quality assessment using: Allocation concealment for RCTs. Disagreements resolved by discussion. |
Data extraction | Data extraction by one reviewer. Quality check: 100% checked for accuracy by a second reviewer. Disagreements resolved by discussion. | Data extraction by one reviewer. Quality check: Random sample of 40% extracted independently by second reviewer. Disagreements resolved by discussion. |
Analysis | Reviews/RCTs categorised according to the question(s) that they answered: • Does supported self-management reduce healthcare utilisation and improve control? • For which target groups does it work? • Which components contribute to effectiveness? • In what healthcare contexts does supported self-management work? Meta-Forest plots for pooled statistics of the primary outcome (healthcare utilisation). Narrative synthesis within categories. | Meta-analysis: Standardised mean differences (random effects model) to examine the effects of self-management support interventions on hospitalisation rates, A&E attendances, quality of life and total costs. Permutation plots of the data from trials reporting both utilisation (hospitalisation rates, A&E attendances or total costs) and health outcomes (quality of life). |
Interpretation | Monthly teleconferences to enable synergies between PRISMS and RECURSIVE. End-of-project stakeholder conference to discuss findings and implications for commissioning and providing services for people with LTCs. |
Assessment of methodological quality
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*** Large high-quality review
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** Either small high-quality review or large low-quality review
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* Small low-quality review
Outcomes
Extraction of data
Data analysis
Reference and weighting*; RCTs, n; Participants, n; R-AMSTAR; Date range of included RCTs | Comparison | Relevance to meta-review questions: | Interventions included | Target group(s) | Synthesis | Main results |
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What is the impact? Target groups? Which components? Context? | ||||||
Bailey 2009 [25]** 4 RCTs 617 participants R-AMSTAR 36 RCTs 2000–2008 | Culturally orientated programmes vs. usual care or limited/generic education. FU (mode): 12 mo, range 4–12 mo | Impact Target: Ethnic groups | Education, action plans, triggers and avoidance, collaboration with healthcare services. Language-appropriate asthma educators. | Minority groups: Puerto Rican, African-American, Hispanic, Indian sub-continent. Adults and children. | Meta-analysis Narrative analysis | Reduced hospitalisation in children (RR 0.32, 95% CI 0.15–0.70; 1 RCT) but not reported in adults. Improved QoL in adults (WMD 0.25, 95% CI 0.09–0.41; 2 RCTs). 2 of 2 RCTs reported a reduction in A&E visits and hospitalisations: one reported no difference in ‘use of healthcare resources’; 2 of 3 reported improved QoL (adults). |
Bernard-Bonnin 1995 [26]** 11 RCTs 1290 participants R-AMSTAR 27 RCTs 1981–1991 | Interactive teaching on self-management vs. standard care. | Impact Target: Children | Interactive teaching (one-to-one or group) to support asthma self-management. | Children 1–18 y. Overall severity classified as ‘mild to moderate’. | Meta-analysis Narrative analysis | Reduced hospitalisation (ES 0.06 ± −0.08) and emergency visits (ES 0.14 ± 0.09); 5 RCTs. Children with high baseline numbers of hospitalisations and emergency visits had greatest subsequent reduction in morbidity. |
Bhogal 2006 [23]** 4 RCTs 355 participants R-AMSTAR 41 RCTs 1990–2004 | Symptom-based written PAAPs vs. peak flow-based PAAP. FU (mode): 3 mo, range 3–24 mo | Target: Children Components: PEF vs. symptom monitoring | Asthma education plus PAAPs for both parents and children. Generally contained 3 steps: often employing ‘traffic lights’. Monitoring varied: either daily or when symptomatic. | Children 6–19 y with mild to severe asthma. | Meta-analysis | Symptom-based PAAPs reduced unscheduled care compared to peak flow-based PAAPs (RR 0.73, 95% CI 0.55–0.99; 4 RCTs). No difference in hospital admissions (RR 1.51, 95% CI 0.35–6.65. Peak flow-based PAAPs reduced the number of symptomatic days/week (MD 0.45 days/week, 95% CI 0.04–0.26; 2 RCTs). No significant difference for adult or child QoL. |
Zemek 2008 [24]** 5 RCTs 423 participants R-AMSTAR 41 RCTs 1990–2005 | Written PAAPs vs. no PAAP. Symptom-based vs. PEF-based PAAP. FU (mode): 3 mo, range 0.5–24 mo | Impact: Target: Children Components: PAAP | Education for parents and children, plus PAAPs, with 3 steps: often employing ‘traffic lights’. Monitoring varied: either daily or when symptomatic. | School-aged children with mild to severe asthma. | Meta-analysis | A PEF-based PAAP reduced unscheduled care compared to no plan (WMD −0.50, 95% CI −0.83 to −0.17; 1 RCT). A PEF-based PAAP compared to no plan reduced symptom scores (WMD −11.80, 95% CI −18.22 to −5.38) and number of school days missed (WMD −1.03, 95%CI −1.85 to −0.21; 1 RCT). |
Boyd 2009 [27]*** 38 RCTs 7843 participants R-AMSTAR 39 RCTs 1985–2007 | Education targeting children/parents vs. low intensity education. FU (mode): 12 mo range 4–12 mo | Impact: Target: Children, A&E attendees | Education plus therapy review, self-monitoring, PAAPs, and trigger avoidance. Range of settings and professionals and mode of delivery. | Children 0–18 y who had attended A&E for asthma within the previous 12 mo. | Meta-analysis Subgroup analyses | Education reduced A&E attendances (RR 0.73, 95% CI 0.65–0.81; 17 RCTs), admissions (RR 0.79, 95% CI 0.69–0.92; 18 RCTs) and unscheduled consultations (RR 0.68, 95% CI 0.57–0.81; 7 RCTs). No effect on QoL (WMD 0.13, 95% CI 0.73–0.99; 2 RCTs). Subgroup analyses (type and timing of intervention, timing of outcome assessment or age of participants) did not change findings. |
Bussey Smith 2009 [28]* 9 RCTs 957 participants R-AMSTAR 26 RCTs 1986 - 2005 | Computerised education vs. traditional self-management FU (mode): 12 mo, range 3–12 mo | Impact: Components: Technology-based interventions | Interactive computerised educational asthma programmes (games tailored to the individual, web-based education, interactive communication devices). | Patients 3–75 y. 7 RCTs in children, 2 in adults; 4 RCTs in urban or inner-city populations. | Narrative analysis | 1 of 4 improved hospitalisation, and 1 of 5 reduced unscheduled care. 5 of 9 studies found statistical improvements in asthma symptoms compared to control. |
Chang 2010 [29]** 1 RCT 113 participants R-AMSTAR 40 RCT 2010 | Education by IHWs vs. education no IHW. FU: 12 mo | Impact: Target: Ethnic groups | Initial clinical consultation, reinforced by home visits from a trained IHW. Personalised, child-friendly, culturally appropriate education materials. | African-American and Hispanic communities. Children 1–17 y; mean ~7 y. | Narrative analysis | There was no effect on hospitalisations (OR 1.58, 95% CI 0.37–6.79) or A&E attendances (OR 0.30, 95% CI −0.17 to 0.77; 1 RCT). Days absent from school were reduced by 21% in the intervention group (95% CI 5–36%; 1 RCT). Carer asthma QoL was not significantly different (MD 0.25, 95% CI −0.39 to 0.89). |
Coffman 2009 [30]** 18 asthma RCTs 8077 participants R-AMSTAR 29 RCTs 1987-2007 | School-based asthma education vs. usual care. | Impact: Target: Schoolchildren | School-based education on asthma, medication, monitoring, avoiding triggers. Delivered by nurses, health educators, peer counsellors, teachers, ± computer programmes. | Children 4–17 y. Severity: mild to severe, majority were Black or Latino. | Narrative analysis | Unscheduled healthcare was not reported. School absences significantly reduced in 5 of 13 RCTs. Days with symptoms were reduced in 3 of 8 RCTs. Nights with symptoms improved in 1 of 4 RCTs: 1 found improvement in the control group. QoL improved in 4 of 6 RCTs. |
Gibson 2002 [31]*** 36 RCTs 6090 participants R-AMSTAR 39 RCTs 1986 –2001 | Self-management programmes vs. usual care. | Impact: Components: Regular review Context: LTC care | Education (100%); self-monitoring of symptoms or PEF (92%); regular review by a medical practitioner (67%); PAAP (50%). Subgroup analyses based on these service models. | Adults and children. Range of settings, including hospital, emergency room, outpatients, community setting, general practice. | Meta-analysis Subgroup analysis | Self-management reduced hospitalisations (RR 0.64, 95% CI 0.50–0.82; 12 RCTs), A&E visits (RR 0.82, 95% CI 0.73–0.94; 13 RCTs] and unscheduled consultations (RR 0.68, 95% CI 0.56–0.81; 7 RCTs). Self-management reduced days off work/school (RR 0.79, 95% CI 0.67–0.93; 7 RCTs) and improved QoL (SMD 0.29, 95% CI 0.11–0.47; 6 RCTs). Optimal self-management (supported by a PAAP and regular review) reduced hospitalisations (RR 0.58, 95% CI 0.43–0.77; 9 RCTs), and A&E visits (RR 0.78, 95% CI 0.67–0.91; 9 RCTs). |
Gibson 2004 [32]*** 26 RCTs 6090 participants R-AMSTAR 39 RCTs 1987–2002 | Different components of written PAAPs vs. usual care. | Components: PAAPs | Complete PAAPs specified when/how to increase treatment (n = 17); incomplete omitted advice on increasing ICS (n = 4); non-specific (n = 5) only had general instructions. | Adults and children. Variety of settings, including hospital, emergency room, outpatients, community setting, general practice. | Action points % predicted vs. % best Treatment advice Non-specific plans | Benefits were found for any number of action points (2 to 4). Both % predicted and % best reduced hospitalisations, but only % personal best reduced A&E visits. PAAPs which included advice on increasing ICS and starting oral steroids reduced hospitalisations and A&E visits. Efficacy of incomplete and non-specific PAAPs was inconclusive. |
Moullec 2012 [33]** 18 RCTs 3006 participants R-AMSTAR 27 RCTs 1990–2010 | Interventions to improve inhaled steroid adherence vs. usual care. FU (mode): 12 mo, range 0.25–24 mo | Context: LTC care | All studies included self-management; some included components of CCM: decision support, delivery system design, clinical information systems. | Moderate to severe asthma (one RCT included COPD). Aged 35–50 y. Women over-represented. | Meta-analysis | Effect size for adherence to ICS compared by number of components of the CCM in the study: 1 CCM component (n = 13): small ES 0.29 (95% CI 0.16–0.42) 2 CCM components (n = 5): large ES 0.53 (95% CI 0.40–0.66) 3 CCM components (no studies) 4 CCM components (n = 4) very large ES 0.83 (95% CI 0.69–0.98). |
Newman 2004 [34]** 18 asthma RCTs (of 63 RCTs) 2004 participants R-AMSTAR 23 RCTs 1997 –2002 | Self-management interventions vs. standard care/basic information. | Impact: | Individual/group interventions, focused on symptom monitoring, trigger avoidance and adherence to medication. A few used techniques to address barriers to effective self-management. | Adults with 3 LTCs (including asthma). | Narrative analysis and comparison between interventions | 7 of 11 studies reported a reduction in unscheduled healthcare. 6 of 12 studies reported improved QoL. 3 of 8 studies reported reductions in severity of symptoms, all used education and action plans. 8 of 14 reported improved adherence. |
Postma 2009 [35]** 7 RCTs 2316 participants R-AMSTAR 23 RCTs 2004–2008 | CHWs vs. usual care. FU (mode): 12 mo, range 4–24 mo | Impact: Target: Ethnic groups, children | CHWs from the same community as participants. Education on asthma, lifestyle and trigger avoidance, with resources to reduce allergen exposure. | Children 5–9 y with allergies and low-income. Mainly African-American and Hispanic. | Narrative review | 3 of 6 studies reported reduced hospitalisation and reduced unscheduled consultations. 4 of 6 reported reduced A&E attendances ‘Consistent and significant decrease in caregiver-reported asthma symptoms among intervention subjects compared with control subjects in 6 studies.’ |
Powell 2009 [36]*** 15 RCTs 2460 participants R-AMSTAR 34 RCTs 1990–2001 | Self-management vs. physician-reviewed management. Comparison of modified PAAPs. | Components: PAAP, regular review Context: LTC care | Self- vs. physician adjustment of medication (n = 6 studies). PEF vs. symptoms PAAPs (n = 6). Other variations (n = 3). | Adults with asthma recruited from a range of primary, community, A&E and secondary care. | Self- vs. physician management Symptoms vs. PEF-modified PAAPs | Of 6 studies: 4 reported no difference in hospitalisation, 1 reported no difference in A&E visits, 3 reported inconsistent effects on unscheduled consultations. Of 6 studies, 6 reported no difference in hospitalisation, 5 reported inconsistent effects on A&E visits. Omitting regular review (1 RCT) or reducing intensity of education (1 RCT) increased unscheduled consultations. Verbal (vs. written) PAAPs had no effect on hospitalisations or A&E visits (1 RCT). |
Ring 2007 [37]*** 14 RCTs 4588 participants R-AMSTAR 35 RCTs 1993– 2005 | Interventions encouraging use of PAAPs vs. usual care. | Context: Organisation of care | Interventions promoting PAAP ownership or use. Diverse interventions (educational, prompting, asthma clinics, asthma management systems, quality improvement). | Adults or children with moderate to severe asthma; some post-exacerbation. | Narrative analysis | 4 of 5 studies of education, 1 of 2 studies of telephone consultations, 1 of 2 studies of asthma clinics and 1 of 2 studies of asthma management systems reported increased PAAP ownership. 1 study of self-management education, 1 of 2 studies of telephone consultations and 1 of 2 studies of asthma management systems increased understanding/use of PAAPs. |
Tapp 2007 [38]*** 13 RCTs 2157 participants R-AMSTAR 39 RCTs 1979–2009 | Asthma education at A&E visit vs. usual care. FU (mode): 6 mo, range 2–18 mo | Impact: Target: Post A&E attendance | Asthma education provided by asthma or A&E nurses within a week of A&E visit included PAAPs, triggers, monitoring, inhalers and medication. | Adults recruited during A&E attendance. | Meta-analysis Narrative analysis | The intervention reduced hospital admissions (RR 0.50, 95% CI 0.27–0.91; 5 RCTs), A&E visits (RR 0.66, 95% CI 0.41–1.07; 8 RCTs). Effect on QoL (2 RCTs) was inconsistent. There was no effect on days off work/school. |
Toelle 2004 [39]** 7 RCTs 967 participants R-AMSTAR 38 RCTs 1990– 2001 | Written PAAP vs. no plan. Symptom vs. PEF-based PAAP. FU (mode): 12 mo, range 6–12 mo | Components: PAAP | Peak flow-based written PAAP or symptom-based written PAAP delivered in primary or tertiary care. | Adults 28–45 y and children in 1 RCT. | Meta-analysis Subgroup analysis | Unscheduled healthcare: assessed in 1 RCT, not reported by systematic review. No difference between symptom and peak flow-based PAAPs in hospitalisations (RR 1.17, 95% CI 0.31–4.43; 3 RCTs) or A&E attendances (RR 1.17, 95% CI 0.31–4.43; 3 RCTs). Symptom-based PAAPs were more effective at reducing unscheduled consultations (RR 1.34, 95% CI 1.01–1.77; 2 RCTs). |
Welsh 2011 [40]*** 12 RCTs 2342 participants R-AMSTAR 41 RCTs 1986–2010 | Home-based self-management vs. routine care or general education. FU (mode): 12 mo, range 6–24 mo | Impact: Target: Children | Language-appropriate education (asthma, triggers, medication, inhalers, self-management with PAAPs). Also homework, technology devices, 24-hour hotline. | Children (mostly <12 y) recruited from recent healthcare visit. Mainly ethnic and/or deprived communities in USA. | Meta-analysis Narrative analysis | No difference between groups in mean number of A&E visits (MD 0.04, 95% CI −0.20 to 0.27; 2 RCTs). 2 of 5 studies reported hospitalisation: one found a reduction and one an increase in the intervention group. Effect on A&E visits (6 RCTs) was inconsistent. Overall no effect on QoL was found in 5 studies. |
Bravata 2009 [41]*** 63 RCTs 13,476 participants R-AMSTAR 40 RCTs 1966–2006 | Self-management QI vs. other QI strategies. | Impact: Target: Children | Self-monitoring or self-management. Patient/caregiver education. Provider education. Organisational change and interventions with multiple QI strategies. | Children <18 y. | Meta-analysis | Interventions targeting parents/caregivers reduced hospitalisation rates by 1.2% per year (95% CI 0.1–2.4; n = 5). Self-management intervention studies improved symptom-free days by 2.8% (95% CI 0.6–5.0), which equalled 0.8 days per month (n = 7); and reduced monthly school absenteeism by 0.4% (95% CI 0–0.7), which equalled 0.1 day per month (n = 16). Longer duration of intervention increased the effect on school absences. |
Denford 2014 [43]*** 38 RCTs 7883 participants R-AMSTAR 36 RCTs 1993–2000 | Asthma self-care vs. usual/less intensive intervention. FU (mode): 12 mo, range 3–18 mo | Impact: Components: Behaviour change | Commonest behavioural change techniques including: self-monitoring (n = 30), instruction (n = 27), goal-setting (n = 26) and inhaler technique (n = 24). | Adults ≥18 y with a diagnosis of asthma. | Meta-analysis | Intervention group participants had reduced asthma symptoms (SMD −0.38, 95% CI −0.52 to 0.24; 27 RCTs) and unscheduled healthcare use (OR 0.71, 95% CI 0.56–0.9; 23 RCTs). Increased adherence to preventative medication compared to control (OR 2.55, 95% CI 2.11–3.10; 16 RCTs). |
de Jongh 2012 [42]** 1 asthma RCT (of 4) 16 participants R-AMSTAR 35 RCTs 1993–2009 | Mobile phone messaging for self- management vs. usual care. FU: range 4–12 mo | Components: Mobile phone messaging | Self-management interventions delivered by mobile phone messaging. | Participants of all ages, gender or ethnicity. Included any LTC (one asthma study). | Narrative synthesis | In the single asthma study, there were fewer admissions (2 vs. 7) but more unscheduled consultations (21 vs. 15) in the intervention group compared to the usual care group. The pooled asthma symptom score showed a significant difference between groups, favouring the intervention group (MD −0.36, 95% CI −0.56 to −0.17). |
Kirk 2012 [44]** 10 asthma RCTs 2195 participants R-AMSTAR 23 RCTs 1995–2010 | Self-care support vs. usual care. FU (mode): 12 mo, range 3–24 mo | Impact: Target: Children | Interventions aiming to help children take control of and manage their condition, promote their capacity for self-care and/or improve their health. | Children ≤18 y with a LTC: asthma (10 RCTs), cystic fibrosis (2) or diabetes (1). | Narrative synthesis | Of 8 RCTs, 2 reported fewer asthma admissions, 5 reported fewer A&E attendances and 2 of 3 reported fewer unscheduled consultations. Control improved in 5 of 8 RCTs. Qol improved in 2 of 5 RCTs. |
Marcano Belisario 2013 [45]** 2 RCTs 408 participants R-AMSTAR 39 RCTs 2000–2013 | Self-management apps vs. traditional self-management. FU: 6 mo | Components: Smartphone Apps | Self-management support interventions provided by smartphone app. | Adults with clinician-diagnosed asthma. | Narrative synthesis | Of 2 RCTs, 2 reported no difference in hospital admissions; 1 reported fewer A&E attendances compared to control; 1 found no difference in unscheduled GP consultations or out of hours consultations, but reduced primary care nurse consultations; 1 reported no difference in MD in Asthma Control Questionnaire scores between the intervention and control group at 6 months; 1 found improved QoL in the intervention group. |
Press 2012 [46]*** 5 RCTs (of 15 studies) 1459 participants R-AMSTAR 34 RCTs 1950–2010 | Interventions targeted at ethnic minority groups vs. usual care. FU (mode): 6 mo, range 0.25–32 mo | Impact: Target: Ethnic groups | Interventions targeting ethnic populations in US. 15 were education-based, 9 were system-level interventions, 5 were culturally tailored and community-based, 10 were hospital-based. | Adults ≥18 y. Ethnic minority groups: African-Americans (10 studies, Latinos (4 studies). | Narrative synthesis | An education intervention reduced A&E attendance in 2 of 4 RCTs and hospital admissions in 2 of 3 RCTs. Symptoms were not reduced in any of the 3 RCTs that measured control. QoL was improved in 3 of 4 RCTs that used an asthma-related QoL outcome. |
Stinson 2009 [47]* 4 asthma RCTs (of 9 studies) 826 asthma participants R-AMSTAR 28 RCTs 1993–2008 | Internet-based self-management vs. usual care. FU (mode): 12 mo, range 3–12 mo | Target: Children Components: Internet-based | Any Internet-based or enabled self-management intervention. | Children 6–12 y or adolescents 13–18 y with LTCs: asthma (4 RCTs), pain (1), encopresis (1), brain injury (1) or obesity (1). | Narrative synthesis | 1 RCT reported no difference in hospitalisations compared to control, 1 RCT reported significant reductions in A&E visits and 1 of 2 RCTs showed fewer unscheduled consultations. 4 out of 4 reported significant improvement in a measure of control. 1 of 4 asthma RCTs reported a significant benefit on QoL. |
Reference and weighting; Participants, n; Risk of bias | Comparison | Relevance to meta-review questions: | Study type and interventions included | Target group(s) | Main results [1o] is the defined primary outcome |
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What is the impact? Target groups? Which components? Context? | |||||
Al-Sheyab 2012 [48] n = 261 HIGH risk of bias | Adolescent Asthma Action programme vs. standard care. FU: 3 mo | Target: Adolescents Components: Peer education | Cluster RCT. Triple A. Peer leaders from year 11 were trained to deliver programme to years 8, 9 and 10. | Adolescents in Jordanian high school. I group had fewer females, fewer symptoms and higher English proficiency. | Compared to control improvements QoL score improved [I: 5.42 (SD 0.14) vs C: 4.07 (SD 0.14) MD 1.35 (95%CI 1.04–1.76)]. |
Baptist 2013 [49] n = 70 HIGH risk of bias | Personalised asthma self-regulation intervention vs. education session. FU 12 mo | Target: Older adults Components: Health educator | RCT. 6-session programme (group telephone). Patients selected an asthma-specific goal, and addressed potential barriers. Control is single session basic education + 2 telephone calls. | Aged ≥65 y. Physician diagnosis of asthma, no restriction in severity. Majority Caucasian. | No between-group differences in A&E visits or hospitalisations. Healthcare utilisation was lower at 6 mo but not 12 mo. ACQ was similar at 1 mo and 6 mo. At 12 mo, I participants were 4.2 times more likely to have an ACQ score <0.75. [1o] QoL (mAQLQ) was significantly higher in the I than in C at all time points (1, 6 and 12 mo). |
Ducharme 2011 [50] n = 219 LOW risk of bias | ‘Take-home plan’ post A&E visit with PAAP + prescription information vs. prescription but no PAAP/information. FU: 28 days | Target: Children, A&E attendees Components: PAAP with prescription | RCT. Intervention is written PAAP with a ‘formatted’ prescription for ICS (i.e. including information about use) issued by A&E doctor on discharge following asthma exacerbation. | Canadian children 1–17 y recruited during A&E attendance for acute asthma (78% were under the age of 6 y). | No between-group differences in unscheduled care at 28 days. Compared to control, at 28 days children given the PAAP had better asthma control (proportion with Asthma Quiz Score <2 I: 58% vs. C: 41%; RR 1.36, 95% CI 1.04–1.86). No between-group differences in child/caregiver QoL at 28 days. [1o] Adherence to ICS declined from 90% (day 1) to 50% at day 14, with no significant group difference. |
Goeman 2013 [51] n = 114 Low risk of bias | Person-centred education vs. written information. FU: 12 mo | Target: Older adults Components: Personalised education | RCT. Personally tailored education session with asthma educator based on responses to a questionnaire; inhaler technique. | ≥55 y, community-based asthmatics with no restriction in asthma severity. | [1o] At 12 mo I participants had better asthma control than C (ACQ MD 0.3, 95% CI 0.06–0.5, p = 0.01) and better asthma-related QoL (p = 0.01). No significant difference in number of steroid courses (p = 0.17). At 12 mo, more I participants (n = 36, 61%) owned a PAAP compared to C (n = 21, 38%; p = 0.015). [1o] Similar adherence to ICS at 12 mo (p = 0.015). |
Halterman 2014 [52] n = 638 LOW risk of bias | Personalised prompts for clinicians and parents, practice training and feedback vs. written guidelines. FU: 6 mo | Target: Children, deprived communities Components: Feedback Context: Community-based, clinical training | Cluster RCT. Intervention practices received personalised clinician and parent prompts + blank PAAP; practice training; feedback. Control practices sent guidelines. | Urban, primary care practices in deprived communities. Parents/children 2–12 y with persistent, poorly controlled asthma. Recruited from waiting room over 4 ystudy. | 11% in both groups had an A&E visit or hospitalisation. [1o] Compared to control practices, at 2 mo children in the PAIR-UP practices had more symptom-free days [I: 10.2 days/2 weeks (SD 4.8) vs. C: 9.5 days/2 weeks (SD 5.1); MD 0.78, 95% CI 0.29–1.27] but the difference was not significant at 6 mo. Nights with symptoms remained significant at 6 mo [I: 1.4 (SD 3.0) vs. C: 1.8 (SD 3.2); MD −0.43; 95% CI −0.77 to −0.09]. |
Horner 2014 [53] n = 183 UNCLEAR risk of bias | Asthma plan for kids vs. teaching on general health and well-being. FU: 12 mo | Target: Children, rural communities | Cluster RCT. Programme delivered in 16 × 15 min sessions, 3 days/week for 5.5 weeks, by school nurses during lunch break + home visit. | Grades 2–5 (ages 7–11 y) with physician diagnosis of asthma. | No between-group difference for admissions or A&E visits. No between-group difference in QoL scores. Inhaler skill improved in the intervention group compared to control after 4 mo, with reported higher self-efficacy. |
Joseph 2013 [54] n = 422 UNCLEAR risk of bias | Web-based asthma management intervention vs. control. FU: 12 mo | Target: Adolescents, urban deprived, ethnic groups Components: Web-based, behavioural change | RCT. Internet-based programme targeted at African-Americans/urban adolescents with traits (low motivation; low perceived emotional support; resistance to change; rebelliousness). | Grades 9–12 (ages 14–18 y) with physician diagnosis of asthma and report >4 days of restricted activity in the past 30 days at baseline. | No difference in reported A&E visits/hospitalisations at 12 mo. [1o] Compared to C, at 12 mo the I participants had fewer symptom-days (RR 0.8, 95% CI 0.6–1.0). No difference in nights with symptoms, schooldays missed, days of restricted activity or days had to change plans. Students characterised with rebelliousness or low perceived emotional support reported fewer symptom-days. |
Khan 2014 [55] n = 91 HIGH risk of bias | Asthma education + individualised written PAAP vs. asthma education (excluding PAAP). | Target: Ethnic groups Components: Written PAAP | RCT. Both groups received individual asthma education during an OPD visit from a paediatrician + monthly FU. Intervention group trained in using a PAAP. | 1–14 y. Recruited via A&E OPD with partly controlled asthma (daytime or nocturnal symptoms, activity limitation, lung function < 0% best or exacerbation in previous year). | [1o] Trend for improved outcomes at 6 mo but no significant between-group difference in proportion of children attending A&E (I: 36% vs. C: 52%; p = 0.141). There was no between-group difference in unscheduled doctor visits, asthma attacks, missed school days or night-time awakenings. |
Rhee 2011 [56] n = 112 UNCLEAR risk of bias | Peer-led asthma education provided by peers at a day camp vs. adult-led camp. | Target: Adolescents. Components: Peer leaders | RCT. Asthma self-management skills + psychosocial skills taught at a day camp by peer leaders + monthly peer telephone contact. Control: Similar education delivered by adults. No telephone. | 13–17 y (including low-income families). Mild/moderate/severe asthma. Asthma diagnosis for 1 y. Able to understand spoken and written English. | [1o] Both groups reported significantly increased QoL over time (F = 4.31, p = 0.002), with I group having significantly higher QoL at 6 mo (MD 11.38, 95% CI 0.96–21.79, p = 0.03) and 9 mo (MD 12.97, 95% CI 3.46–22.48, p = 0.008). Both groups reported improved attitude to asthma (F = 11.94, p = 0.001), with greater improvement in I at 6 mo (MD 4.11, 95% CI 0.65–7.56, p = 0.02). |
Rikkers-Mutsaerts 2012 [57] n = 90 UNCLEAR risk of bias | Internet-based self –management vs. usual care. FU: 12 mo | Target: Adolescents. Components: Internet-based | RCT. Internet-based self-monitoring with algorithm-based advice. Programme included education (web-based + group), self-monitoring (FEV1 + ACQ), PAAP and 3–6 mo review. | 12–18 y with mild to severe persistent asthma on regular ICS medication and poorly controlled at recruitment. | No between-group differences in exacerbations, physicians’ visits or telephone contacts. [1o] QoL was better in I group at 3 mo (PAQLQ I: 6.00 vs. C: 5.68; MD 0.40, 95% CI 0.17–0.62) but not at 12 mo (I: 5.93 vs. C: 6.05; MD 0.05, 95% CI 0.50–0.41). Asthma control was improved in I group at 3 mo (ACQ I: 0.96 vs. C: 1.19; MD −0.32, 95% CI −0.56 to −0.08) but not at 12 mo (I: 0.83 vs. C: 0.79; MD −0.05, 95% CI −0.35 to 0.25). |
Shah 2011 [58] 150 GPs and 201 children LOW risk of bias | GP training (PACE study) vs. no training. FU: 12 mo | Targets: Children Components: GP training | Cluster RCT. GPs participated in 2 × 3-h workshops on communication and education strategies to facilitate quality asthma care. | 150 GPs and 221 children with asthma in their care. | No between-group difference in hospitalisation/A&E visits (I: 18% vs. C: 12%; difference 6%, 95% CI −4 to 15). No between-group differences in school absence or parent absenteeism for child’s asthma. [1o] More patients in I group GPs had a PAAP (I: 61% vs. C: 46%; difference 15%, 95% CI 2–28). |
van Gaalen 2013 [59] n = 107 HIGH risk of bias | Internet-based self –management vs. control (FU of SMASHING trial). FU: 30 mo | Target: Adults Components: Internet-based | RCT (FU study). Education + PAAP, self-monitoring and regular review. The 200 patients in original 12-mo trial were invited for FU after 18 mo. | Adults with asthma aged 18–50 y, using ICS. 107/200 (54%) participated: I group: 47/101 (47%); C group: 60/99 (61%). Participants ACQ was similar, but AQLQ was greater than in non-participants. | At 30 mo after baseline, there was a slightly attenuated improvement for both QoL (AQLQ adjusted between-group MD 0.29, 95% CI 0.01–0.57) and ACQ (adjusted MD of −0.33, 95% CI −0.61 to −0.05) scores in favour of the intervention. No between-group differences in FEV1. |
Wong 2012 [60] n = 80 HIGH risk of bias | Symptom-based written PAAP vs. verbal counselling. FU: 6 mo | Target: Children, ethnic groups Components: Written PAAP | Single blinded RCT. Intervention was symptom-based PAAP given out at initial contact. Outcomes measured at baseline, 3, 6 and 9 mo. | Malaysian children (mix of Malay, Chinese and Indian) with all severities of asthma. Aged 6–17 y. Recruitment process not described. | At 6 mo there was no difference in A&E visits/unscheduled care [intervention 4 (SD 10.8) vs. control 6 (SD 21.1); p = 0.35]. At 6 mo there was no difference in proportion controlled (ACT ≥ 20 I: 81% vs. C: 87%; p = 0.50), with no exacerbations (ACT ≥ 20 I: 89% vs. C: 82%; p = 0.62) or in QoL [mean PAQLQ I: 6.11 (SD 0.88) vs. 6.11 (SD 1.09); p = 0.99]. |
Interpretation and end-of-project workshop
Lay involvement
Updating of searches prior to publication
Results
Description of the studies in the meta-review
Study quality and weight of evidence
Reference; Country; Allocation concealment | Study type; Participants, n; Intervention(s) | Comparison | Target group(s) | Health economic results | Formal health economic evaluation, cost-effectiveness (societal and health service perspective) | |||
---|---|---|---|---|---|---|---|---|
Quality of life/asthma control | Healthcare utilisation (hospitalisation) | Total healthcare costs | Unscheduled care | |||||
Baptist 2013 [49] US Concealment not adequate | RCT n = 70 Personalised 6-session self-regulation education. | Usual care. FU: 12 mo | Older adults with asthma (>65 y). Mean age 74 y. 14% male. | Proportion with ACQ <0.75 was greater in I group than C group [I: 13 (41.9%) vs. C: 5 (15.6%)]. | I group had fewer hospitalisations (I: 0 vs. C: 4; p = 0.04). | n/a | No difference in A&E visits (I: 1 vs. C: 2; p = 0.58). I group had fewer unscheduled visits (I: 6 vs. C:14; p = 0.048). | n/a |
Castro 2003 [69] US Concealment not adequate | RCT n = 96 Education, psychosocial support, PAAP and co-ordination of care. | Usual (private) primary care. FU: 12 mo | Inpatients, adults with asthma. Mean age 38 y. 15% male. | No between-group difference in mean AQLQ [I: 4.0 (SD 1.3) vs. C: 3.9 (SD 1.5); p = 0.55]. | I group had fewer re-admissions/patient [I: 0.4 (SD 0.9) vs. C: 0.9 (SD 1.5); p = 0.04]. | I group had lower costs/patient [I: $5726 (SD 5679) vs. C: $12,188 (SD 19,352); MD $6,462; p = 0.03]. | No between-group differences in number A&E visits/patient [I:1.9 (SD 4.3) vs. C: 1.4 (SD = 1.5); p = 0.52]. | n/a |
Clark 2007 [70] US Concealment not adequate | RCT n = 808 Self-regulation intervention; nurse telephone-delivered. | Usual care. FU: 12 mo | Adult women with asthma. Mean age 49 y. 100% female | No between-group difference in mean AQLQ [I: 2.1 (SD 0.9) vs. C: 2.1 (SD 0.9]. | No between-group difference in admissions/patient [I: 0.2 (SD 0.7) vs. C: 0.1 (SD 0.5)] | n/a | I group had greater reduction in unscheduled visits [mean change: I: −0.63 (SD 2.4) vs. C: −0.24 (SD 1.5)]. | n/a |
de Oliveira 1999 [71] Brazil Concealment not adequate | RCT n = 52 Outpatient education programme, including a written PAAP. | Usual care. FU: 6 mo | Adults; moderate to severe asthma. Mean age 38 y. 15% male. | No between-group differences in QoL score [I: 28 (SD 17) vs. C: 50 (SD 15); p = 0.0005]. | No between-group differences in admissions/patient [I: 0 vs. C: 0.5 (SD 0.8); p = 0.08]. | n/a | I group had fewer A&E visits/patient [I: 0.7 (SD 1.0) vs. C: 2 (SD 2)]. | n/a |
Gallefoss 2001 [72] Norway Concealment not adequate | RCT n = 78 Group-plus individual self-management education with a written PAAP. | Usual primary care. FU: 12 mo | Adults with asthma. Mean age 44 y. 21% male. | Better QoL (SGRQ) in I group at 12 mo [I: 20 (SD 15) vs. C: 36.5 (SD 18); MD 16.3, 95% CI 16.3–24.4] | n/a | No between-group differences in total costs (in NOK) [I: 10,500 (SD 20,500) vs. C: 16,000 (SD 35,400); p = 0.510]. | n/a | Incremental SGRQ gain 16.3; health costs difference NOK1900; all cost diff NOK −5500. |
Gruffydd-Jones 2005 [73] UK Concealment not adequate | RCT n = 174 Targeted nurse-led telephone reviews, including PAAPs. | Usual primary care. FU: 12 mo | Adults with asthma. Mean age 50 y. 40% male. | No between-group difference in mean change in ACQ [I: −0.11 (95% CI −032 to 0.11) vs. C: −0.18 (95% CI −0.38 to 0.02); p = 0.349]. | n/a | No between-group difference in total costs [I: £209.85 (SD 220.94) vs. C: £333.85 (SD 410.64); MD £122.35; p = 0.071]. | n/a | n/a |
Honkoop 2015 [74] Netherlands Adequate concealment | RCT n = 611 Nurse-led care to symptom control (I) (or FeNO controlled). | Usual care (partially controlled). FU: 12 mo | Adults with asthma. Mean age 40 y. 28% male. | No between-group difference in EQ5D (QALYs) (I: 0.91 vs. C: 0.89; MD 0.01, 95% CI −0.02 to 0.04). | n/a | No between-group difference in total costs [I: $4591 vs. C: $4180; MD $411, 95% CI −904 to 1797; p > 0.05]. | n/a | n/a |
Kauppinen 1998 [75] Finland Concealment not adequate | RCT n = 162 Intensive education (use of inhaled drugs, PEF, monitoring and PAAP). | Conventional education. FU: 12 mo | Adults, newly diagnosed asthma. Mean age 43 y. 44% male. | No between-group difference in 15D [I: 0.93 (95% CI 0.90–0.94) vs. C: 0.91 (95% CI 0.89 to 0.94); p = 0.47]. | n/a | I group had greater total costs than control [I: £345 (95% CI 247–1758) vs. C: £294 (95% CI 0–8078); p < 0.001]. | n/a | Intensive education: incremental gain of 0.02 15D. Incremental difference in health costs of £51. |
Krieger 2015 [76] US Adequate concealment | RCT n = 366 Community health worker-supported self-management. | Usual care. FU: 12 mo | Adults with asthma. Mean age 41 y. 27% male. | Intervention improved QoL. Mean change in mAQLQ (I: 0.95 vs. C: 0.36; MD 0.50, 95% CI 0.28–0.71; p <0.001). | No difference in mean change in number of urgent care episodes. (I: −1.50 vs. C: −1.60; difference 0.09, 95% CI −0.59 to 0.73; p = 0.78.) | n/a | n/a | n/a |
Lahdensuo 1996 [77] Finland Concealment not adequate | RCT n = 122 Self-management, including breathing exercises, education and PEF monitoring. | Traditional treatment. FU: 12 m | Adults with asthma. Mean age 43 y. 48% male. | Intervention improved QoL SGRQ (symptom domain) [I: 16.6 (SD 15.9) vs. C: 8.4 (SD 18.4); p = 0.009]. | n/a | n/a | I group had fewer unscheduled care visits/patient/year (I: 0.5 vs. C:1; p = 0.04). | n/a |
Levy 2000 [78] UK Concealment not adequate | RCT n = 211 Structured education with PAAP by A&E specialist nurses. | Usual primary care. FU: 6 mo | Adults with asthma. Mean age 40 yrs. 43% male. | No between-group difference in SGRQ (I: 30.25 vs. C: 28.73; MD 1.52, 95% CI −4.05 to 7.09). | No between-group difference in hospital consultations [median (IQR) I: 0 (1–3) vs. C: 0 (1–6); p = 0.17]. | n/a | No between-group difference in GP consultations [median (IQR) I: 0 (1–7) vs. C: 0 (1–7); p = 0.14]. | n/a |
Mancuso 2011 [79] US Concealment not adequate | RCT n = 296 Self-management workbook, behavioural contract, telephone calls. | Information/PEF training. FU: 12 mo | Adults attending A&E with asthma. Mean age 43 y. 23% male. | No between-group difference in change in AQLQ at 1 y (I: 0.04 vs. C: 0.18; MD 0.22, 95% CI −0.15 to 0.60). | n/a | n/a | No between-group difference in proportion with A&E visits (I: 13% vs. C: 11%). | n/a |
McLean 2003 [80] Canada Adequate concealment | RCT n = 225 Pharmacist-led self-management, with PAAP. | Usual pharmacist care. FU: 7 mo | Adults with asthma. Mean age 38 y. 47% male. | Intervention improved QoL as mean AQLQ (I: 5.13 vs. C: 4.40; p = 0.0001). | No between-group difference in hospitalisations (I: 0.078 vs. C: 0.16; p = 0.94). | Intervention reduced total costs (costs per patient I: $150 vs. C: $351). | No between-group difference in A&E visits (I: 0.04 vs. C: 0.21; p = 0.48). | n/a |
Moudgil 2000 [81] UK Concealment not adequate | RCT n = 689 Individual education and optimisation of drug therapy. | Usual primary care. FU: 12 mo | Adults with asthma. Mean age 35 y. 47% male. | Greater improvement in QoL in I group (MD in change in AQLQ 0.22 , 95% CI 0.15–0.29). | No between-group difference in hospitalisations (OR 0.51, 95% CI 0.22–1.14). | n/a | No between-group difference in A&E visits (OR 0.63, 95% CI 0.23–1.68). | n/a |
Pilotto 2004 [82] Australia Concealment not adequate | Cluster RCT n = 170 Nurse-run asthma clinics including provision of PAAPs. | Usual primary care. FU: 9 mo | Adults with asthma. Mean age 50 y. 48% male. | No between-group difference in SGRQ (I: 27.3 vs. C: 27.0; MD −0.5 (−4.0 to 2.9). | No between-group difference in number admitted (I: 2 vs. C: 0; p = 0.499). | n/a | No between-group difference in number attending A&E (I: 2 vs. C: 0; p = 0.499). | n/a |
Pinnock 2003 [83] UK Adequate concealment | RCT n = 278 Nurse-delivered, routine telephone review. | Usual primary care. FU: 3 mo | Adults with asthma. Mean age 57 y. 41% male. | No between-group difference in mAQLQ (I: 5.17 vs. C: 5.17; MD 0.22, 95% CI −0.15 to 0.60). | No patients in either group had a hospital admission for asthma. | n/a | No patients in either group had an A&E attendance for asthma | n/a |
Price 2004 [84] UK Adequate concealment | Cluster RCT n = 1553 Use of PAAPs with adjustable maintenance dosing. | Usual care. FU: 3 mo | Adults with asthma. Mean age 48 y. 41% male. | No between-group difference in proportion with improved QoL (I: 22.5% vs. C: 23.6%). | No between-group difference in hospital admissions (I: 2 vs. C: 2). | Intervention reduced total costs (cost/day/patient I: £1.13 vs. C: £1.31; MD − £0.17, 95% CI -£0.11 to -£0.23). | No between-group difference in A&E visits (I: 5 vs. C: 11). | n/a |
Ryan 2012 [85] UK Adequate concealment | RCT n = 288 Mobile phone supported self-management. | Paper-based PAAPs. FU: 6 mo | Adults with asthma. Mean age 52 y. 41% male. | No between-group difference in mean change in mAQLQ (difference −0.10, 95% CI −0.16 to 0.34). | No between-group difference in hospital admissions for asthma (I: 3 vs. C: 1). | n/a | No between-group difference in A&E attendances for asthma (I: 3 vs. C: 0). | n/a |
Schermer 2002 [86] Netherlands Concealment not adequate | RCT n = 193 Guided self-management with education and PEF monitoring. | Usual primary care. FU: 24 mo | Adults with asthma. Mean age 39 y. 42% male. | No between-group difference in total AQLQ (I: 39 vs. C: 29; MD 10, 95% CI −3 to 23). | No hospital admissions in either treatment group. | No between-group difference in total costs (I: €1084 vs. C: €1097; MD − €13). | No A&E visits in either treatment group. | Incremental QALY gain 0.015. Incremental total cost − €13. Incremental health cost €11. Incremental health ICER €33/QALY. |
Shelledy 2009 [87] US Concealment not adequate | RCT n = 166 Nurse- (N) vs. respiratory therapist-(RT) led education and management. | Usual primary care. FU: 6 mo | Adults: A&E or admitted with asthma. Mean age 44 y. 22% male. | RT I group had greater change in SGRQ [I(RT) −11.0 vs. I(N) −6.0 vs. C: −2.5, p < 0.05). | I group had fewer hospitalisations [I(RT): 0.04 vs. I(N): 0 vs. C: 0.20; p < 0.05). | I group had lower hospitalisation costs [I(RT): $202 vs. I(N): $0 vs. C: $1065; p < 0.05]. | No between-group difference in A&E visits [I(RT): 0.09 vs. I(N): 0.26 vs. C: 0.37)]. | n/a |
Sundberg 2005 [88] Sweden Concealment not adequate | RCT n = 97 Interactive computer-based education plus nurse support. | Usual care. FU: 12 mo | Young adults with asthma. Mean age 19 y. 55% male. | No between-group difference in Living with Asthma Questionnaire (I: 163.6 vs. C: 166.2, p > 0.05). | No between-group difference in hospital admissions (1 admission in each group). | n/a | No between-group difference in A&E visits (I: 17 vs. C: 16). | n/a |
van der Meer 2011 [89] Netherlands Concealment not adequate | RCT n = 200 Internet-based self-management programme, including electronic PAAP. | Usual outpatient care. FU: 12 mo | Adults with asthma. Mean age 37 y. 55% male. | No between-group difference in EQ5D (I: 0.93 vs. C: 0.89; difference 0.006, 95% CI −0.042 to 0.054). | No between-group difference in hospital admissions (mean cost: I: $571 vs. C: $589; MD −17; p = 0.95). | No between-group difference in total healthcare costs (I: $2555 vs. C: $2518; MD − $37; p = 0.94). | n/a | Incremental QALY gain 0.024. Incremental total cost $641. Incremental health cost $37. Incremental health ICER $1541/QALY. |
Yilmaz 2002 [90] Turkey Concealment not adequate | RCT n = 80 Outpatient clinic, special education programme. | Usual primary care. FU: 36 mo | Adults with asthma. Mean age 29 y. 37% male. | I group had greater improvements in AQLQ (I: 197.1 vs. C: 176.7; p = 0.009). | No between-group difference in hospitalisations (I: 0 vs. C: 4); p > 0.05. | n/a | I group had fewer A&E visits (I: 0 vs. C: 7; p = 0.01). | n/a |
Yoon 1993 [91] Australia Concealment not adequate | RCT n = 76 Brief, group-based, education with a PAAP. | Usual outpatient care. FU: 10 mo | Inpatient adults. Mean age not reported. 28% male. | No between-group difference in QoL [I: 4.0 (SD 4.38) vs. C: 3.96 (SD = 3.34); p > 0.05). | I group had fewer participants with hospital admissions (I: 1 vs. C: 7; p < 0.001). | n/a | No between-group difference in A&E visits (I: 3 vs. C: 7). | n/a |
Overview of presentation of results
Reference; RCTs, n; Participants, n; Date range RCTs | Comparison | Relevance to meta-review questions: | Interventions included | Target group(s) | Synthesis | Main results |
---|---|---|---|---|---|---|
What is the impact? Target groups? Which components? Context? | ||||||
Systematic reviews | ||||||
Coelho 2016 [61] 17 RCTs; 5879 participants RCTs 2005–2013 | School-based asthma education vs. usual care. FU: minimum 1 mo | Target: Schoolchildren | Educational interventions to individuals, groups or classes by healthcare professionals, teachers, educators and/or IT. | Schoolchildren with asthma and/or whole school. | Narrative analysis | 6/17 showed a reduction in unscheduled care; 5/17 showed a reduction of the asthma symptoms; 5/17 reduced school absenteeism; 7/17 improved QoL of the individuals; 8/17 showed that asthma education improved knowledge. |
McLean 2016 [62] 5 RCTs 595 participants RCTs 2011–2013 | Interactive digital interventions vs. usual care. FU: 10 weeks to 12 mo | Impact Components: Technology-based interventions | Interactive intervention (i.e. entering data, receiving tailored feedback, making choices) accessed through an app that provides self-management information. | Adults (≥16 y) with asthma. | Meta-analysis | Meta-analyses (3 studies) showed no significant difference in asthma control (SMD 0.21, 95% CI −0.05 to 0.42) or asthma QoL (SMD 0.05, 95% CI −0.22 to 0.32) but heterogeneity was very high. Removal of the outlier study reduced heterogeneity and indicated significant improvement for both asthma control (SMD 0.54, 95% CI 0.22–0.86) and asthma QoL (SMD 0.45, 95% CI 0.13–0.77). |
Randomised trials
| ||||||
Hoskins 2016 [63] 48 participants | Goal-setting + SM/PAAPs vs. usual care. | Components: Goal-setting | Practice asthma nurses trained in goal-setting approach. | Primary care patients due a review. | Cluster feasibility RCT. FU: 6 mo | Difficulty recruiting: 10/124 practices participated and 48 patients. No between-group difference in QoL [mAQLQ I: 6.20 (SD 0.76, 95% CI 5.76–6.65) vs. C: 6.1 (SD 0.81, 95% CI 5.63–6.57), MD 0.1]. |
Morawska 2016 [64] 107 participants | Generic parenting skills vs usual care. | Components: Parenting skills | Parenting skills for managing LTCs + asthma ‘take-home tips sheets’. | Parents of children 2–10 y with asthma and/or eczema. | RCT. FU: 6 mo | Between-group improvement in parents’ self-efficacy and childs’ ‘eczema behaviour’, but not equivalent asthma outcomes. Parent and family generic QoL improved (p = 0.01). |
Plaza 2015 [65] 230 participants | Trained practices (I) vs. specialist unit (Is) vs. usual care (C). | Impact: Components: Education programme | Basic information on asthma, inhaler technique; provision of a PAAP. | Adults with persistent asthma. | Cluster RCT. FU: 12 mo | I groups had fewer unscheduled visits [I: 0.8 (SD 1.4) and Is: 0.3 (SD 0.7) vs. C:1.3 (SD 1.7); p = 0.001], and greater improvements in asthma control (p = 0.042) and QoL (p = 0.019). |
Rice 2015 [66] 711 participants | PAAP + inpatient lay educator vs. PAAP. | Components: Inpatient lay educator | Encourage FU attendance, build self-efficacy, set goals, overcome barriers. | Children 2–17 y admitted with asthma. | RCT. FU: 1 mo | No difference in attendance at FU appointment. I group had greater preventer use (OR 2.4, 95% CI 1.3–4.2), PAAP ownership (OR 2.0, 95% CI 1.3–3.0) and improved self-efficacy (p = 0.04). |
Yeh 2016 [67] 76 participants | Family programme (+PAAP) vs. usual care (+PAAP). | Components: Family empowerment | Family empowerment to reduce parental stress, increase family functioning. | Children 6–12 y with asthma. | RCT. FU: 3 mo | I families had reduced parental stress index (p = 0.026) and improved family environment scores (p < 0.0001), improved lung function, less disturbed sleep, less cough but no difference in wheeze. |
Zairina 2016 [68] 72 participants | Telehealth supported PAAP vs. usual care. | Components: Telehealth | Telehealth (FEV1, symptoms) monitored weekly. | Pregnant women with moderate/severe asthma | RCT. FU: 6 mo | Telehealth improved ACQ [MD 0.36 (SD 0.15, 95% CI −0.66 to −0.07)] and mAQLQ [MD 0.72 (SD 0.22; 95% CI 0.29–1.16)]. No difference in perinatal outcomes. |
Can supported self-management reduce the use of healthcare resources and improve asthma control?
Use of healthcare resources
Events/total participants | Percentage of participants with the event | |||
---|---|---|---|---|
Intervention | Control | Intervention | Control | |
Proportion hospitalised | ||||
Boyd 2009 [27]*** | 276/2009 | 351/2010 | 13.7 | 17.4 |
Gibson 2002 [31]*** | 85/1200 | 139/1218 | 7.1 | 11.4 |
Tapp 2007 [38]*** | 40/286 | 74/286 | 14.0 | 25.9 |
RECURSIVE | 80/1727 | 124/1734 | 4.6 | 7.2 |
Proportion with A&E attendances | ||||
Boyd 2009 [27]*** | 337/1505 | 462/1503 | 22.4 | 30.7 |
Gibson 2002 [31]*** | 291/1457 | 354/1445 | 20.0 | 24.5 |
Tapp 2007 [38]*** | 74/472 | 104/474 | 15.7 | 22.0 |
RECURSIVE | 153/1171 | 227/1170 | 13.1 | 19.4 |
Proportion with unscheduled visits | ||||
Boyd 2009 [27]*** | 128/515 | 181/494 | 24.9 | 36.6 |
Gibson 2002 [31]*** | 112/784 | 170/772 | 14.3 | 22.0 |
Asthma control
In which target groups has supported self-management been shown to work?
Group | Key strategies | Description of tailoring of self-management intervention | Relevant systematic reviews/update RCTs | Evidence |
---|---|---|---|---|
Cultural groups | Cultural tailoring | Culturally orientated self-management programmes including individual sessions with language-appropriate asthma educators, videos/workbooks featuring culturally appropriate role models, education appropriate to socioeconomic context, strategies for use of local healthcare services, asthma action plans. | **Bailey 2009 [25] Adults and children from minority groups | Culture-specific programmes are more effective than generic programmes in improving QoL, knowledge and asthma control but not all asthma outcomes. |
Culturally tailored, community-based interventions in which healthcare providers (pharmacists, asthma educator, social workers, respiratory nurses) provided language-appropriate education programmes including health literacy-focused teaching, use of videos, asthma physiology and management, inhaler technique, PAAP. | ***Press 2012 [46] Adults from minority groups in the USA | The 5 (of 15) education studies that were culturally tailored showed reduced use of unscheduled care and improved QoL, but this is not compared to non-tailored interventions. | ||
Internet-based programme developed to deliver education and a behaviour change intervention to African-Americans adolescents. Strategies include voice-overs to accommodate literacy limitations and advice delivered by a ‘disc jockey’. | (RCT) Joseph 2013 [54] Young teens | The intervention reduced symptom-free days but had no effect on A&E visits/hospitalisations. | ||
Community workers | Community health worker from the same/very similar community as participating families provided individually tailored education at home visits. Topics included asthma, lifestyle and trigger avoidance, with resources to reduce allergen exposure and smoking cessation support. | **Postma 2009 [35] Ethnic minority children with asthma | Interventions involving community health workers reduced emergency and urgent care use in some but not all studies. | |
Indigenous healthcare workers provided personalised, child-friendly, culturally appropriate education materials at home visits to reinforce clinical consultations. | **Chang 2010 [29] Ethnic minority children with asthma | The involvement of indigenous healthcare workers in asthma programmes (1 RCT) improved control and QoL but not unscheduled care. | ||
A&E attendees | Education during the A&E attendance | Education sessions conducted by asthma or A&E nurses, or, less often, respiratory specialists or a physiotherapist. Content varied, usually including triggers, PAAPs and/or inhaler technique. | ***Tapp 2007 [38] Adult A&E attendees | Education delivered in A&E reduced subsequent hospital admissions but not A&E attendances. Effect on QoL was inconsistent. |
PAAP, completed by the A&E physician, coupled with the prescription provided on discharge from A&E. | (RCT) Ducharme 2011 [50] Children 1–17 y, A&E attendees | Provision of a PAAP increased patient adherence to steroids (oral/inhaled), and improved asthma control. | ||
Education after A&E | Education delivered by a healthcare professional or asthma educator shortly after an A&E attendance, including triggers and PAAPs, to the child and their carers. | ***Boyd 2009 [27] Children, A&E attendees | Asthma education reduced A&E attendances and admissions, but had no effect on QoL. | |
Schoolchildren | School-based programmes | School-based group education, the majority including education for classmates without asthma. | **Coffman 2009 [30] Children | The intervention improves knowledge, self-efficacy and self-management behaviours, but inconsistent effect on asthma control. |
16 short group educational sessions, including strategies for problem solving, delivered in the school lunch break. | Horner 2014 [53] Grades 2–5 (7–11 y) | Compared to generic health education, the intervention improved self-efficacy but had no effect on admissions, A&E visits or QoL. | ||
Peer-led programmes | Year 11 pupils were trained to deliver the school-based asthma educational lessons to younger pupils. | Al-Sheyab 2012 [48] Adolescents | Compared to children in control schools, knowledge and QoL improved. Also increased self-efficacy to resist smoking. | |
Asthma self-management skills and psychosocial skills taught at a day camp by peer leaders followed by monthly peer telephone contact. | Rhee 2011 [56] Adolescents 13–17 y | The intervention group had improved QoL and positive ‘attitude to illness’ compared to those attending adult-led camps. | ||
Technology-based | Internet-based interventions, delivered at home, clinic or school, which delivered a psycho-educational programme involving information and skills training modules targeting improved health outcomes. | **Stinson 2009 [47] Children 4–17 y | The majority of studies reported improvement in symptoms, but impact on other outcomes was inconsistent. | |
Theoretically based asthma computer programme with core modules (adherence, inhaler use, smoking reduction), with tailored sub-modules to address specific behavioural traits. | Joseph 2013 [54] 9–12 grade (14–18 y) | The intervention improved symptom control, but had no effect on A&E visits/hospitalisations. | ||
Internet-based self-management programme covering education, self-monitoring and an electronic action plan, and encouraging regular medical review. Supported by 2 face-to-face groups. | Rikkers-Mutsaerts 2012 [57] Adolescents 12–18 y | QoL and asthma control improved compared to usual care, but no difference in use of healthcare resources. | ||
Elderly | Goal-setting | Six-session programme, conducted by a health educator in groups (n = 3) and telephone calls (n = 3). Participants selected an asthma-specific goal, identified problems and addressed potential barriers. | (RCT) Baptist 2013 [49] ≥65 y | Compared to education alone, the intervention improved asthma control and QoL, but not unscheduled care. |
Addressing individual concerns | Specific concerns, identified with the Patient Assessment and Concerns Tool (PACT), were addressed in an hour-long session. Both groups had standard education (inhaler technique, PAAP). | (RCT) Goeman 2013 [51] ≥55 y | Compared to usual care, asthma control and QoL was improved by education tailored to individual patient concerns and unmet needs. |