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

Hilary Pinnock, Hannah L Parke, Maria Panagioti, Luke Daines, Gemma Pearce, Eleni Epiphaniou, Peter Bower, Aziz Sheikh, Chris J Griffiths, Stephanie J C Taylor, PRISMS and RECURSIVE groups, Stephanie J C Taylor, Hilary Pinnock, Chris J Griffiths, Trisha Greenhalgh, Aziz Sheikh, Eleni Epiphaniou, Gemma Pearce, Hannah L Parke, Anna Schwappach, Neetha Purushotham, Sadhana Jacob, Peter Bower, Maria Panagioti, Gerry Richardson, Elizabeth Murray, Anne Rogers, Anne Kennedy, Stanton Newman, Nicola Small, Hilary Pinnock, Hannah L Parke, Maria Panagioti, Luke Daines, Gemma Pearce, Eleni Epiphaniou, Peter Bower, Aziz Sheikh, Chris J Griffiths, Stephanie J C Taylor, PRISMS and RECURSIVE groups, Stephanie J C Taylor, Hilary Pinnock, Chris J Griffiths, Trisha Greenhalgh, Aziz Sheikh, Eleni Epiphaniou, Gemma Pearce, Hannah L Parke, Anna Schwappach, Neetha Purushotham, Sadhana Jacob, Peter Bower, Maria Panagioti, Gerry Richardson, Elizabeth Murray, Anne Rogers, Anne Kennedy, Stanton Newman, Nicola Small

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.

Keywords: Asthma; Health economic analysis; Meta-analysis; Supported self-management; Systematic meta-review.

Figures

Fig. 1
Fig. 1
PRISMA flowchart. Note: The initial RECURSIVE search included all long-term conditions: papers reporting asthma randomised controlled trials (RCTs) were identified from 184 studies included in the full RECURSIVE report [14]
Fig. 2
Fig. 2
Meta-Forest plot of healthcare resource use from meta-analyses. This meta-Forest plot displays the summary data from the PRISMS systematic reviews that reported relative risk (RR). Note that meta-analysis is inappropriate at meta-review level owing to the overlap of included randomised controlled trials between reviews
Fig. 3
Fig. 3
Meta-analysis of total costs. CI confidence interval, ES effect size
Fig. 4
Fig. 4
Permutation plot. Quality of life (x-axis), hospitalisations (y-axis blue) and total costs (y-axis red). In this permutation plot, the effects of self-management interventions on outcomes (quality of life) and utilisation (hospitalisations and total costs) can be visualised simultaneously by placing them in quadrants of the cost-effectiveness plane depending on the pattern of outcomes. Such plots identify studies in the appropriate quadrant (i.e. those that reduce costs without compromising outcomes) and those in problematic quadrants (i.e. those that reduce costs but also compromise outcomes, or those that compromise both outcomes and costs).

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