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Table 2 Overview of the findings of the included studies

From: Implementing supported self-management for asthma: a systematic review and suggested hierarchy of evidence of implementation studies

Study Design, size and quality Intervention Outcomes
Patient Professional Organisation Health service utilisation Disease control and QoL Process
Primarily professional training
Cleland 2007 [39]
Primary care
Cluster RCT. FU: 6m 13 practices: 629 adults with poorly controlled asthma, Quality score = 24 None Intervention: one 3-hour interactive seminar vs. control None Not assessed Routine data: SABA use and steroid courses: NS Sub-group: QoL (miniAQLQ): I: 6.49 (95%CI 6.40 to 6.59) vs C: 6.33 (95%CI 6.23 to 6.44) P = 0.03 (less than MCID of 0.5) Asthma control: NS Not assessed
Homer 2005 [30]
Primary care
Cluster RCT. FU 12m 43 practices: 13,878 children with asthma Quality score = 18 None Three one-day group training + two additional sessions + biweekly conference calls Intended implementation of CCM Admissions and ED visits: no between group differences reported Asthma attacks and exercise limitation: no between group differences reported Ownership of PAAP: I: 54% vs C: 41% (but large baseline difference) Use of preventer medication: I: 38% vs C: 39% Use of ICS I: 15% vs C: 17%
Primarily patient education
Delaronde 2005 [32]
Managed Care Organisation
Preference RCT. FU 12 (‘opt-in’ ‘opt-out’ ‘probably’ group were randomised) 399 adults, Quality score = 20 Six-minute nurse-led telephonic case management vs usual care None None Physician office visits, emergency department visits, hospitalisations: NS Sub-group: No significant difference in the change in QoL (I: 0.26 vs C: 0.12) and within group changes < the MCID Ratio of preventer to reliever medication. Increase in intervention group (0.18) was greater than in the control group (0.09) P = 0.04. Increase in the ‘opt-in’ group was greater at 0.29 (P = 0.01)
Vollmer 2006 [35]
Managed Care Organisation
RCT, 6,948 adults, (192 had live calls) Quality score = 18 Three 10-minute automated calls providing asthma review and personalised feedback None Provided as a service by the MCO No between group difference in admissions/ED visits (% patients I: 4.1% vs C: 4.0% P = 0.88) or other unscheduled care Asthma control: No difference in QoL (miniAQLQ I: 5.2 (SD 1.2) vs C: 5.1 (SD 1.2) P = 0.48) or any measure of asthma control Medication use: No difference in ICS (% using ≥6 canisters/year I: 30.4% vs C: 29.8% P = 0.60)
Bunting 2006 [31]
Managed Care Organisation
Repeated measures study, eight years of routine data 207 adults, Quality score=17 One-to-one education + PAAP by a hospital based asthma educator. Sessions lasted 60 to 90 minutes + regular follow-up for five years by pharmacists. None Pharmacist and medication costs reimbursed by health plans. From insurance claims: ED visits or hospitalisations /100 patients/y were lower during the programme (5.4, 2.6, 1.9, 5.4, 0) than in three years before (21.3, 22.2, 22.3) Compared to baseline, at most recent follow up reduced: PAAP ownership increased from 63% at baseline to 99% at follow-up (P <.0001)
• % severe /moderate asthma B: 77% vs FU: 49% P <0.001
• working days lost B: 2.5/patient/year vs FU 0.5/patient/year
Forshee 1998 [33]
Managed Care Organisation
Before and after study over 24 weeks 201 adults/children with poorly controlled asthma, Quality score = 15 Tailored individualised education + videos + handouts Nurse champions were educated about asthma None Compared to baseline, at follow up patients had: Compared to baseline, at follow up patients had: Monthly reviews, knowledge and confidence (non-validated questionnaire) increased significantly for both adults and children
• Fewer episodes of unscheduled care (P ≤0.01) • Improved severity classification (P <0.001)
• Improved QoL (P ≤0.001)
• Fewer days off work B: 6.5 vs FU: 3.9 (P <0.05)
Gerald 2006 [34]
Inner city elementary schools
Cluster RCT, 54 schools, 736 children, Quality score = 18 6 × 30 minute group education sessions for pupils with asthma + a clinical assessment with a paediatric allergist who developed a PAAP None Asthma education was provided for school staff A 30 minute classroom lesson was given to all children in grades I to IV in the school Compared to control, intervention children had no difference in: Compared to control, intervention children had: Compared to control, school education resulted in a statistically significant increase in knowledge (P <0.0001) in 17 of the 18 schools
• ED visits/child I: 0.09 (SD 0.28) vs C: 0.10 (SD 0.31) • No difference in absenteeism : 3.88 days/child/year (SD 3.5) vs C: 3.21 (SD 3.2).
• Admissions/child
• d: 0.04 (SD 0.19) vs C: 0.02 (SD 0.14)
Chini 2011 [47]
Primary schools
Before-and-after 2,765 children: 135 with asthma, Quality score = 15 Clinical assessment and were given a PAAP with FU review at end of the year. Age-appropriate groups taught cognitive and breathing techniques None Lessons aimed at teachers, school personnel, parents, and schoolchildren to improve their knowledge of asthma Not assessed At the end of the year improved: Not assessed
• PedsQL: B: 2.2 (SD 0.79) vs FU: 3.5 (SD 0.73) P <0.001
• Parents’ perception of child’s QOL B: 3.1 (SD 0.6) vs FU: 3.5 (SD 0.4) P = 0.004
• Asthma symptoms (P <0.001)
Primarily organisational change
Kemple 2003 [40] UK Primary care RCT, 545 adults, Quality score = 20 None None Organisational intervention enclosing PAAPs (blank=I (AAP) or personalised= I (PAAP)) with invitations to review There were no significant differences in admissions or out-of-hours consultations over the subsequent 12 months There were no significant differences in prescriptions of short-acting beta2 agonists, peak flow, steroid courses Compared to control OR of a review (95%CI): I (AAP): OR 1.92 (1.18 to 3.11); I (PAAP): OR 2.33 (1.37 to 3.93)
Sub-group: Compared to control, OR of changing RCP3Qs score: I (AAP): OR 1.43 (0.80 to 2.56); I (PAAP): OR 1.46 (0.81 to 2.61) Sub-group: Compared to control OR of understanding of self-management (95%CI): I (AAP): OR 1.28 (0.66 to 2.45); I (PAAP): OR 2.20 (1.13 to 4.30)
Pinnock 2007 [41]
Primary care
Controlled implementation trial, 1,809 adults and children, Quality score = 21 Usual asthma review, including provision (or review) of self-management (with PAAP). Existing practice asthma nurses who already had an accredited diploma on asthma care Three reminders to patients due a review, with an option to book a telephone or face-to-face review. Opportunistic telephone calls to non-responders. Not assessed Sub-group: Compared to the control group, patients in the TC-option group had More patients reviewed (I: 66.4% vs C: 53.8% risk difference 12.6% (95% CI 7.2 to 17.9))
• no difference in asthma control (ACQ mean (SD): I: 1.20 (1.00) vs C: 1.33 (1.13) mean diff 0.12 (−0.06 to 0.31) Sub-group: Patients in the TC option group had greater:
• enablement: P = 0.03
• no difference in asthma QoL • confidence managing asthma (P = 0.007).
Lindberg 2002 [48]
Primary care
Cross-sectional survey, 8 practices: 347 adults + random sample of 20/practice for survey Quality score = 16 The ANP provided regular review, including patient asthma education including a PAAP. The Asthma Nurse Practitioner (ANP) had specialist asthma training. With the exception of emergency visits and the yearly follow-up visit to their physician all visits were made to the asthma nurse Patients from ANP centre had: Survey (non-validated) Patients from ANP centre were less likely to Clinical records
• No difference in hospitalisations (I: 2.2% vs C: 3.7% NS) • wake at night (P <0.01) ANP centre was:
• Lower proportion of consultations (I: 43% vs C: 56% P <0.05) • have activity limitation (P < 0.05) • More likely record PF
• 18% lower total healthcare costs. • have ≥2 asthma attacks in 6m (P <0.05) • Discuss smoking
  ANP centre patients had: Survey (non-validated)
  • No difference in health status (EQ5D) ANP centre patients were more likely to:
  • Increased sick leave. • own PAAP (P <0.001)
   • use a PF meter
   • have knowledge about asthma (P <0.001)
A whole systems approach
Haahtela 2006 [45]
Primary, secondary and community settings
10 year ITS, Population of Finland, Quality score = 10 (Note: many of the criteria did not apply) Patient organisations arranged direct patient counselling and distributing information and resources free of charge Education was provided for 5,300 respiratory specialists, 3,700 primary/secondary care professionals, 25,500 other healthcare professionals, 695 pharmacists The Finnish Ministry of Social Affairs and Health recognised asthma as an important public health issue and set up the national programme Over the 10 year programme: Over the 10 year programme: Over the 10 year programme:
• Admissions fell from 110,000 to 51,000/year • Sick leave decreased (from 2966 to 1920) • Diagnosed asthmatics increased (from 225,000 to 350,000)
• Deaths fell from 123 to 85/year • Number of people with asthma receiving disability payments decreased from 7212 to 1741 • Proportion using ICS increased (33% to 85%)
• ED visits fell • Deaths fell from 123/year to 85/year • Smoking levels remained constant,
• Costs fell (from €1611 to €1031 per patient)   
Kauppi 2012 [46] This publication reports follow on data from the Haahtela Finnish study (see previous entry). All the descriptive information is therefore the same. In the six years after the end of the programme   In the three years after the end of the programme
• Admissions have continued to fall (from 32,000 hospital days 15,000 hospital days)   • Prevalence of asthma has continued to rise (from 6.8% to 9.4%)
Souza-Machado 2010 [44]
Controlled implementation study over nine years, Population of Salvador and Recife (control city), Quality score = 11 (Note: many of the criteria did not apply) Patient training: individual asthma education + monthly group sessions discussing asthma prevention and treatment 512 primary healthcare physicians, nurses, pharmacists, social workers and managers were trained on asthma and rhinitis Healthcare community project. Centres offered specialist care and free medication to patients with severe asthma At nine years: Over the nine years: in-hospital mortality decreased from 23 deaths in 2003 to one in 2006. (In Recife the in-hospital mortality rate increased from five deaths in 2003 to 6 in 2006) From 2003 to 2006, the programme dispensed 220,889 units of inhaled medication for asthma control. There was a strong inverse correlation between hospitalisation rates and drug dispensation
• Hospitalisation rates per 10,000 inhabitants at nine years: Salvador: 2.25 vs Recife 17.06
• The decline (2003 to 2006) was greater in Salvador (−74.2%) than Recife (−22.2%) P<0.001
Andrade 2010 [43]
Brazil Primary healthcare network
Before and after study, 582 children (470 cases and 112 controls) Quality score = 19 Individual and group educational activities, including PAAP Patient education provided by pharmacists and health workers but no details of their training. Healthcare community project. Free medication At 12 months 5% of cases compared to 34% of controls had unscheduled asthma consultations P <0.01. Not assessed The use of ICS was greater in cases (67%) than controls (not given). All cases (users of the service) had a PAAP
Bunik 2011 [38]
Secondary care paediatric clinics
Five year repeated measures study, 1,797 children clinic attendees, Quality score = 15 Asthma educators provided education about medications and provided PAAPs. Telephone FU two weeks after unscheduled care Monthly education sessions for junior medical staff and nurses. Computer and paper prompts to facilitate structured review with PAAPs Pre-consultation questionnaires for families, templates for asthma reviews, respiratory therapist support for providing education and PAAPs. There was no significant change in the proportion of children with ED visits (B:6% vs FU:6%) and hospitalisations (B:3% vs FU:3%) from 2006 to 2009. Not assessed Children seen three years after the intervention were more likely to:
• Be given a PAAP (aRR 2.86 (95% CI 2.60–3.20)
• Have an assessment of severity (aRR 1.47 (95% 1.41 to 1.54)
• Be prescribed ICS (aRR 1.11 (95% CI 1.05 to 1.19)
Swanson 2000 [42]
Primary Care
Retrospective comparator study, 400 adults and children, Quality score = 16 Asthma self-management education in asthma clinic Professional training in implementing the BTS asthma guideline Provision of paper-based templates Compared to baseline, at follow-up patients in intervention practices were less likely to have had an ED attendance (p<0.05) or unscheduled consultation (p<0.05) Compared to patients in control practices, attendees at intervention practice clinics reported greater improvements in asthma symptoms (p<0.001) Compared to control practices, at FU patients in intervention practices were more likely to:
• have and follow a PAAP (P <0.01)
• have attended a review (P <0.05)
Findley 2011 [37]
Community day care centres for pre-school children
Before-and-after study 35 centres, 1,908 children and their families, Quality score = 17 Parents received asthma education from parent mentors and a PAAP, and were encouraged to talk with their child’s physician. Children played activities and games on asthma triggers Professionals of children enrolled in the programme were offered. Physician Asthma Care Education (PACE) training The centre staff received training on asthma and asthma management (including creating an ‘asthma-friendly centre’), identifying children with asthma, arranging a PAAP and handling emergencies At 9 to 12 months the proportion of children with: At 9 to 12 months the proportion of children with: At 9-12 months:
• Hospitalisations fell from 24% to 11% (P <0.001) • Day-care absences reduced (56% to 38%) • PAAP use increased from 47% to 70%
No ED visits increased from 25% to 53% (P <0.001). • No night-symptoms increased (19% to 52%) (P <0.001) • Staff knowledge increased 49% to 82%
  • No day symptoms: increased ( 22% to 59%) (P <0.001) • Parents’ knowledge increased 62 to 79%;
   • Parents’ confidence increased from 57% to 81% (P <0.001);
Polivka 2011 [38]
Deprived community
Before-and-and after study, 243 children and their families, Quality score = 18 Environmental assessment home repairs, educational home visits to reduce asthma triggers, and provide asthma education and PAAPs Professionals completed the National Center for Healthy Homes practitioners’ course and an asthma educator course. Costs included repair work, contractors, supplies for assessment and education provided to participants At two years children had: At two years children had fewer: At two year follow up:
• fewer emergency consultations (P <0.001)] • day and night symptoms P <0.001 • PAAP ownership increased B: 44% vs FU: 67% P = 0.007
• no difference in admissions P = 0.229 • days with activity limitation (P <0.001)] • asthma knowledge increased (P <0.001)
  • mean days off school B: 5.3 (SD 9.2) vs FU: 1.4 (SD 2.7) P <0.001 • Caregiver
   • self-efficacy increased (P <0.001)
  1. B baseline; C control group; CCM Chronic Care Model; d day; ED Emergency Department; FU follow up; hr hour; I intervention group; ICS inhaled corticosteroid; LABA long acting beta-agonist LTC long-term condition; m month; MCID minimum clinically important difference; min minute; miniAQLQ mini QoL questionnaire; MCO Managed Care Organisation; NS not significant; PAAP personalised asthma action plan; PedsQL Pediatric Quality of Life Inventory 4.0; QoL quality of Life; RCT randomised controlled trial; SABA short acting beta-agonist; w week; y year