Systematic meta-review of supported self-management for asthma: a healthcare perspective

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Abstract

Background

Supported self-management has been recommended by asthma guidelines for three decades; improving current suboptimal implementation will require commitment from professionals, patients and healthcare organisations. The Practical Systematic Review of Self-Management Support (PRISMS) meta-review and Reducing Care Utilisation through Self-management Interventions (RECURSIVE) health economic review were commissioned to provide a systematic overview of supported self-management to inform implementation. We sought to investigate if supported asthma self-management reduces use of healthcare resources and improves asthma control; for which target groups it works; and which components and contextual factors contribute to effectiveness. Finally, we investigated the costs to healthcare services of providing supported self-management.

Methods

We undertook a meta-review (systematic overview) of systematic reviews updated with randomised controlled trials (RCTs) published since the review search dates, and health economic meta-analysis of RCTs. Twelve electronic databases were searched in 2012 (updated in 2015; pre-publication update January 2017) for systematic reviews reporting RCTs (and update RCTs) evaluating supported asthma self-management. We assessed the quality of included studies and undertook a meta-analysis and narrative synthesis.

Results

A total of 27 systematic reviews ( n = 244 RCTs) and 13 update RCTs revealed that supported self-management can reduce hospitalisations, accident and emergency attendances and unscheduled consultations, and improve markers of control and quality of life for people with asthma across a range of cultural, demographic and healthcare settings. Core components are patient education, provision of an action plan and regular professional review. Self-management is most effective when delivered in the context of proactive long-term condition management. The total cost ( n = 24 RCTs) of providing self-management support is offset by a reduction in hospitalisations and accident and emergency visits (standard mean difference 0.13, 95% confidence interval −0.09 to 0.34).

Conclusions

Evidence from a total of 270 RCTs confirms that supported self-management for asthma can reduce unscheduled care and improve asthma control, can be delivered effectively for diverse demographic and cultural groups, is applicable in a broad range of clinical settings, and does not significantly increase total healthcare costs. Informed by this comprehensive synthesis of the literature, clinicians, patient-interest groups, policy-makers and providers of healthcare services should prioritise provision of supported self-management for people with asthma as a core component of routine care.

Systematic review registration

RECURSIVE: PROSPERO CRD42012002694; PRISMS: PROSPERO does not register meta-reviews

Electronic supplementary material

The online version of this article (doi:10.1186/s12916-017-0823-7) contains supplementary material, which is available to authorized users.

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Most cited references 89

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Self-management interventions for chronic illness.

Stanton Newman, Liz Steed, Kathleen Mulligan (2004)

An increasing number of interventions have been developed for patients to better manage their chronic illnesses. They are characterised by substantial responsibility taken by patients, and are commonly referred to as self-management interventions. We examine the background, content, and efficacy of such interventions for type 2 diabetes, arthritis, and asthma. Although the content and intensity of the programmes were affected by the objectives of management of the illness, the interventions differed substantially even within the three illnesses. When comparing across conditions, it is important to recognise the different objectives of the interventions and the complexity of the issues that they are attempting to tackle. For both diabetes and asthma, the objectives are concerned with the underlying control of the condition with clear strategies to achieve the desired outcome. By contrast, strategies to deal with symptoms of pain and the consequences of disability in arthritis can be more complex. The interventions that were efficacious provide some guidance as to the components needed in future programmes to achieve the best results. But to ensure that these results endure over time remains an important issue for self-management interventions.

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Impact of allocation concealment on conclusions drawn from meta-analyses of randomized trials.

J Pildal, A Hróbjartsson, K J Jørgensen … (2007)

Randomized trials without reported adequate allocation concealment have been shown to overestimate the benefit of experimental interventions. We investigated the robustness of conclusions drawn from meta-analyses to exclusion of such trials. Random sample of 38 reviews from The Cochrane Library 2003, issue 2 and 32 other reviews from PubMed accessed in 2002. Eligible reviews presented a binary effect estimate from a meta-analysis of randomized controlled trials as the first statistically significant result that supported a conclusion in favour of one of the interventions. We assessed the methods sections of the trials in each included meta-analysis for adequacy of allocation concealment. We replicated each meta-analysis using the authors' methods but included only trials that had adequate allocation concealment. Conclusions were defined as not supported if our result was not statistically significant. Thirty-four of the 70 meta-analyses contained a mixture of trials with unclear or inadequate concealment as well as trials with adequate allocation concealment. Four meta-analyses only contained trials with adequate concealment, and 32, only trials with unclear or inadequate concealment. When only trials with adequate concealment were included, 48 of 70 conclusions (69%; 95% confidence interval: 56-79%) lost support. The loss of support mainly reflected loss of power (the total number of patients was reduced by 49%) but also a shift in the point estimate towards a less beneficial effect. Two-thirds of conclusions in favour of one of the interventions were no longer supported if only trials with adequate allocation concealment were included.

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Lay perspectives on hypertension and drug adherence: systematic review of qualitative research

Iain Marshall, Charles Wolfe, Christopher McKevitt (2012)

Objective To synthesise the findings from individual qualitative studies on patients’ understanding and experiences of hypertension and drug taking; to investigate whether views differ internationally by culture or ethnic group and whether the research could inform interventions to improve adherence. Design Systematic review and narrative synthesis of qualitative research using the 2006 UK Economic and Social Research Council research methods programme guidance. Data sources Medline, Embase, the British Nursing Index, Social Policy and Practice, and PsycInfo from inception to October 2011. Study selection Qualitative interviews or focus groups among people with uncomplicated hypertension (studies principally in people with diabetes, established cardiovascular disease, or pregnancy related hypertension were excluded). Results 59 papers reporting on 53 qualitative studies were included in the synthesis. These studies came from 16 countries (United States, United Kingdom, Brazil, Sweden, Canada, New Zealand, Denmark, Finland, Ghana, Iran, Israel, Netherlands, South Korea, Spain, Tanzania, and Thailand). A large proportion of participants thought hypertension was principally caused by stress and produced symptoms, particularly headache, dizziness, and sweating. Participants widely intentionally reduced or stopped treatment without consulting their doctor. Participants commonly perceived that their blood pressure improved when symptoms abated or when they were not stressed, and that treatment was not needed at these times. Participants disliked treatment and its side effects and feared addiction. These findings were consistent across countries and ethnic groups. Participants also reported various external factors that prevented adherence, including being unable to find time to take the drugs or to see the doctor; having insufficient money to pay for treatment; the cost of appointments and healthy food; a lack of health insurance; and forgetfulness. Conclusions Non-adherence to hypertension treatment often resulted from patients’ understanding of the causes and effects of hypertension; particularly relying on the presence of stress or symptoms to determine if blood pressure was raised. These beliefs were remarkably similar across ethnic and geographical groups; calls for culturally specific education for individual ethnic groups may therefore not be justified. To improve adherence, clinicians and educational interventions must better understand and engage with patients’ ideas about causality, experiences of symptoms, and concerns about drug side effects.

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Author and article information

Contributors

Hilary Pinnock: +44 (0)131 650 8102 , hilary.pinnock@ed.ac.uk

Hannah L. Parke: hannahlparke@gmail.com

Maria Panagioti: maria.panagioti@manchester.ac.uk

Luke Daines: luke.daines@ed.ac.uk

Gemma Pearce: gemma.pearce@coventry.ac.uk

Eleni Epiphaniou: eleniepi82@gmail.com

Peter Bower: peter.bower@manchester.ac.uk

Aziz Sheikh: aziz.sheikh@ed.ac.uk

Chris J. Griffiths: c.j.griffiths@qmul.ac.uk

Stephanie J. C. Taylor: s.j.c.taylor@qmul.ac.uk

Journal

Journal ID (nlm-ta): BMC Med

Journal ID (iso-abbrev): BMC Med

Title: BMC Medicine

Publisher: BioMed Central (London )

ISSN (Electronic): 1741-7015

Publication date (Electronic): 17 March 2017

Publication date PMC-release: 17 March 2017

Publication date Collection: 2017

Volume: 15

Electronic Location Identifier: 64

Affiliations

[1 ]ISNI 0000 0004 1936 7988, GRID grid.4305.2, Asthma UK Centre for Applied Research, Allergy and Respiratory Research Group, , Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, ; Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG UK

[2 ]ISNI 0000 0001 2171 1133, GRID grid.4868.2, Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, , Queen Mary University of London, ; London, UK

[3 ]ISNI 0000000121662407, GRID grid.5379.8, NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, , University of Manchester, ; Manchester, UK

[4 ]ISNI 0000000106754565, GRID grid.8096.7, Centre for Technology Enabled Health Research (CTEHR), , Coventry University, ; Coventry, UK

Article

Publisher ID: 823

DOI: 10.1186/s12916-017-0823-7

PMC ID: 5356253

PubMed ID: 28302126

SO-VID: 13305d54-6478-4d88-a00a-faabbe06afed

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 28 September 2016

Date accepted : 20 February 2017

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100002001, Health Services and Delivery Research Programme;

Award ID: 11/1014/04

Award ID: 11/1014/06

Award Recipient : Peter Bower

Funded by: FundRef http://dx.doi.org/10.13039/501100000589, Chief Scientist Office;

Award ID: PCRCA_08_01

Award Recipient : Hilary Pinnock

Funded by: Scottish School of Primary Care

Award ID: Academic Fellowship in General Practice

Award Recipient : Luke Daines

Custom metadata

ScienceOpen disciplines: Medicine

Keywords: supported self-management,asthma,systematic meta-review,health economic analysis,meta-analysis

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ScienceOpen disciplines: Medicine

Keywords: supported self-management, asthma, systematic meta-review, health economic analysis, meta-analysis

Systematic meta-review of supported self-management for asthma: a healthcare perspective

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Most cited references 89

Self-management interventions for chronic illness.

Impact of allocation concealment on conclusions drawn from meta-analyses of randomized trials.

Lay perspectives on hypertension and drug adherence: systematic review of qualitative research

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