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Table 5 Summary table of studies included in the RECURSIVE health economic analysis

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

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

  1. Abbreviations: A&E accident and emergency, ACQ Asthma Control Questionnaire, AQLQ Asthma Quality Of Life Questionnaire, C control, CI confidence interval, EQ5D EuroQol Five Dimensions Questionnaire, FeNO fractional exhaled nitric oxide, FU follow-up, GP general practitioner, I intervention, ICER incremental cost-effectiveness ratio, IQR interquartile range, mAQAL mini Asthma Quality Of Life Questionnaire, MD mean difference, mo month, N nurse, n/a not available, PAAP personalised asthma action plan, PEF peak expiratory flow, QALY quality-adjusted life years, QoL quality of life, RCT randomised controlled trial, RT respiratory therapist, SD standard deviation, SGRQ St George’s Respiratory Questionnaire, y year