Systematic meta-review and health economic meta-analysis of supported self-management for asthma: a healthcare perspective Pinnock, H. , Parke, H.L. , Panagioti, M. , Daines, L. , Pearce, G. , Epiphaniou, E. , Bower, P. , Sheikh, A. , Griffiths, C. and Taylor, S.J.C. Published PDF deposited in Coventry University Repository Citation: Pinnock, H. , Parke, H.L. , Panagioti, M. , Daines, L. , Pearce, G. , Epiphaniou, E. , Bower, P. , Sheikh, A. , Griffiths, C. and Taylor, S.J.C. (2017) Systematic meta-review and health economic meta-analysis of supported self-management for asthma: a healthcare perspective. BMC Medicine, 15:64. DOI: 10.1186/s12916-017-0823-7 http://dx.doi.org/10.1186/s12916-017-0823-7 BioMed Central This 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. Copyright © and Moral Rights are retained by the author(s) and/ or other copyright owners. A copy can be downloaded for personal non-commercial research or study, without prior permission or charge. This item cannot be reproduced or quoted extensively from without first obtaining permission in writing from the copyright holder(s). The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the copyright holders.

RESEARCH ARTICLE Open Access

Systematic meta-review of supported self-management for asthma: a healthcareperspectiveHilary Pinnock1*, Hannah L. Parke2, Maria Panagioti3, Luke Daines1, Gemma Pearce4, Eleni Epiphaniou2,Peter Bower3, Aziz Sheikh1, Chris J. Griffiths2, Stephanie J. C. Taylor2 and for the PRISMS and RECURSIVE groups

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 healthcareorganisations. The Practical Systematic Review of Self-Management Support (PRISMS) meta-review and ReducingCare Utilisation through Self-management Interventions (RECURSIVE) health economic review were commissionedto provide a systematic overview of supported self-management to inform implementation. We sought toinvestigate if supported asthma self-management reduces use of healthcare resources and improves asthmacontrol; 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 randomisedcontrolled trials (RCTs) published since the review search dates, and health economic meta-analysis of RCTs. Twelveelectronic databases were searched in 2012 (updated in 2015; pre-publication update January 2017) for systematicreviews reporting RCTs (and update RCTs) evaluating supported asthma self-management. We assessed the qualityof 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-managementcan reduce hospitalisations, accident and emergency attendances and unscheduled consultations, and improvemarkers of control and quality of life for people with asthma across a range of cultural, demographic and healthcaresettings. 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 totalcost (n = 24 RCTs) of providing self-management support is offset by a reduction in hospitalisations and accident andemergency 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 reduceunscheduled care and improve asthma control, can be delivered effectively for diverse demographic and culturalgroups, 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 andproviders of healthcare services should prioritise provision of supported self-management for people with asthma as acore component of routine care.(Continued on next page)

* Correspondence: hilary.pinnock@ed.ac.uk1Asthma UK Centre for Applied Research, Allergy and Respiratory ResearchGroup, Usher Institute of Population Health Sciences and Informatics,University of Edinburgh, Doorway 3, Medical School, Teviot Place, EdinburghEH8 9AG, UKFull list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe 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.

Pinnock et al. BMC Medicine (2017) 15:64 DOI 10.1186/s12916-017-0823-7

(Continued from previous page)

Systematic review registration: RECURSIVE: PROSPERO CRD42012002694; PRISMS: PROSPERO does not registermeta-reviews

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

BackgroundAsthma is common, affecting 334 million people world-wide, and is responsible for substantial morbidity and anincreasing burden on healthcare services globally [1]. Inthe UK, there are over 6 million primary care consulta-tions, and 100,000 hospital admissions each year, at anestimated cost of £1 billion per year [2].For a quarter of a century [3], national and international

guidelines have recommended – unequivocally – thatpeople with asthma should be provided with self-management education reinforced by a personalisedasthma action plan and supported by regular review [4, 5],though mode of delivery, personnel delivering the support,the targeted group and the intensity of the interventionvary [6]. The 2014 UK National Review of Asthma Deathsprovided a stark reminder of the importance of ensuringthat people with asthma respond in a timely and appropri-ate manner to deteriorating symptoms: only 23% haddocumented evidence of having been provided with self-management education and 45% of people who died hadnot sought or received medical attention in their finalattack [7].However, despite self-management being highlighted as

a core component of all models of care for people withlong-term conditions (LTCs) [8–10] and the conceptbeing well established in the context of asthma [4, 5], inpractice only a minority of people with asthma have anaction plan [11]. Effective implementation requires awhole systems approach, combining active engage-ment of patients with the training and motivation ofprofessionals embedded within an organisation inwhich self-management is valued [12]. Patient organi-sations, healthcare professionals, policy-makers, com-missioners and providers of healthcare services thus needan up-to-date systematic overview of the evidence toinform decisions about prioritisation of supported self-management and to underpin implementation strategieswithin diverse healthcare systems.The data presented in this paper are derived from

two parallel programmes of work on supported self-management in LTCs commissioned by the NationalInstitute of Health Research: Practical SystematicReview of Self-Management Support (PRISMS) [13]and Reducing Care Utilisation through Self-managementInterventions (RECURSIVE) [14]. In the context ofasthma, we aimed to answer questions of importance toclinicians, patient-interest groups, managers responsible

for developing healthcare services and policy-makers: cansupported self-management reduce the use of healthcareresources and improve asthma control? More specifically,in which target groups has it been shown to work, whichcomponents are important, in what healthcare contexts,and at what cost?

MethodsWe used established methodology for undertaking ameta-review of systematic reviews (PRISMS) and a sys-tematic review of randomised controlled trials (RCTs)(RECURSIVE) [15]. The PRISMS and RECURSIVE re-views were undertaken during 2012–2013 with initialsearches completed in November 2012 and May 2012,respectively. We updated the PRISMS searches in March2015 with a pre-publication update in January 2017, andthe RECURSIVE searches in September 2015. RECUR-SIVE is registered on PROSPERO: CRD42012002694.(PRISMS could not be registered because PROSPEROdoes not register meta-reviews.)

Search strategyTable 1 summarises the PICOS criteria, search strat-egies, sources and search dates; further details are inAdditional file 1. The PRISMS search strategy in-volved searching nine electronic databases using theterms: ‘self-management support’ AND ‘asthma’ AND‘systematic review’. We defined self-management as‘the tasks that individuals must undertake to live withone or more chronic conditions. These tasks includehaving the confidence to deal with medical manage-ment, role management and emotional managementof their conditions’ [16]. For the update, we searchednot only for systematic reviews published after ourinitial search date but also for RCTs published afterthe search dates used by the included systematicreviews (see Additional file 2 for the details of thesedates). Included systematic reviews were groupedaccording to the populations studied (children, adultsor ethnic minority groups) and the search dates ofthe reviews extracted. Dates for the update RCTsearch were set from the date of the latest reviewsearch within each population group.The RECURSIVE search strategy in nine databases

comprised the terms: ‘self-management support’ AND‘long-term condition’ AND ‘healthcare use’ AND ‘rando-mised controlled trial’. (RECURSIVE included asthma

Pinnock et al. BMC Medicine (2017) 15:64 Page 2 of 32

and other LTCs in a single search.) We also specificallysought health economic publications linked to includedRCTs.

Identification of relevant papersTable 2 summarises the PRISMS and RECURSIVE pro-cesses. Following training (repeated cycles of duplicatescreening of 100 titles, team discussion and clarification ofexclusion rules), one reviewer (HLP or GP for PRISMS;LD for the update; MP for RECURSIVE) reviewed titlesand abstracts and selected possibly relevant studies. A ran-dom sample of titles and abstracts (10% in PRISMS; 40%in RECURSIVE) was examined by a second reviewer (HPfor PRISMS; PB or NS for RECURSIVE) workingindependently as a quality check. The agreement was 97%for the initial search and 99% for the update in PRISMSand 87% for the initial search and 88% for the update inRECURSIVE.After a similar training process, the full texts of all

potentially eligible studies were assessed against the

eligibility criteria (see Additional file 3) by one reviewer(HLP for PRISMS; LD for update; MP for RECURSIVE).Second reviewers undertook a 10% check for PRISMS(HP) and a 30% check for RECURSIVE (PB or NS),achieving 83% and 85% agreement, respectively. Disagree-ments were because unclear papers were included by thereviewer pending discussion with a lead investigator.Uncertainties and disagreements were resolved by fullteam discussion.

Assessment of methodological qualityWe used the R-AMSTAR (Revised Assessment of MultipleSystematic Reviews [17]) quality appraisal tool to assess themethodological quality of the systematic reviews includedin the PRISMS study. This reflects both the quality of thereview process and the rigour with which the reviewassessed the quality of the studies it included. We used theCochrane Risk of Bias tool to assess the quality of RCTs in-cluded in the updated search [15]. Quality assessment wasundertaken by HLP or LD and independently by a second

Table 1 PICOS search strategy and sources for the reviews

PRISMS systematic meta-review RECURSIVE systematic review

Population Adults/children with asthma, from all social anddemographic settings. Multi-condition studies ifasthma data reported.

Adults (≥18 years) with asthma (within a wider searchof long-term conditions), excluding studies in thedeveloping world.

Intervention Self-management support interventions. Self-management support interventions.

Comparator Typically ‘usual care’ or less intense self-managementinterventions.

Typically ‘usual care’ or less intense self-managementinterventions.

Outcomes Unscheduled use of healthcare services (admissions,A&E attendances, unscheduled consultations), healthoutcomes (asthma control), quality of life, processoutcomes (ownership of action plans, self-efficacy).

Healthcare utilisation with comprehensive measures ofcosts or major cost drivers (i.e. hospitalisation, A&Eattendances), 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 theincluded systematic reviews (see Additional file 2).

RCTs

Dates Initial database search: January 1993 (3 years before thepublication of the earliest systematic review identifiedin scoping work) to July 2012. Manual and forwardcitations were completed in November 2012.Update search: March 2015. Pre-publication updateJanuary 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 ofAbstracts of Reviews of Effects, and ISI Proceedings(Web of Science).

CENTRAL, CINAHL, EconLit, EMBASE, Health EconomicsEvaluations Database, MEDLINE, MEDLINE In-Process &Other Non-Indexed Citations, NHS Economic EvaluationDatabase, and the PsycINFO.

Manual searching Systematic Reviews, Health Education and Behaviour,Health Education Research, Journal of BehaviouralMedicine, and Patient Education and Counseling.

Systematic Reviews.

Forward citations On all included systematic reviews. Bibliographies ofeligible 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.

A&E accident and emergency, RCT randomised controlled trial

Pinnock et al. BMC Medicine (2017) 15:64 Page 3 of 32

reviewer (HP) with disagreements resolved by discussionwithin the team (EE, GP, HLP, ST and HP).To reflect both quality and size of the review, we

developed a star weighting system based on (a) the R-AMSTAR score (≥31 was defined as ‘high-quality’) and(b) the number of participants (≥1000 participants wasdefined as ‘large’):

*** Large high-quality review** Either small high-quality review or large

low-quality review* Small low-quality review

In the RECURSIVE study, quality assessment offormal economic evaluations was undertaken usingthe Drummond checklist [18, 19]; RCTs reportinghealthcare utilisation were assessed by judging allo-cation concealment (the quality component most

associated with treatment effect [20]) as adequate orinadequate according to the Cochrane Risk of Biastool [15].

OutcomesThe primary outcome in the PRISMS meta-review wasunscheduled use of healthcare resources (specifically un-scheduled consultations, accident and emergency (A&E)department attendances and hospital admissions). Otheroutcomes of interest were asthma control, asthma-related quality of life and process outcomes (specifically,ownership of action plans). Healthcare utilisation ratesand costs were the primary focus of the RECURSIVE re-view, especially major cost drivers (i.e. hospitalisationrates and costs) and comprehensive summaries includingmultiple sources of cost. The results of formal cost-effectiveness, cost-utility and cost–benefit analyses werealso of interest.

Table 2 PRISMS and RECURSIVE processes for selection of studies, quality assessment, data extraction, analysis and interpretation

PRISMS systematic meta-review RECURSIVE systematic review

Title and abstract screening Initial training.One reviewer selected studies for full-text screening.Quality check: Random sample of 10% checkedindependently 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% checkedindependently 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 possiblyrelevant studies for inclusion.Quality check: Random sample of 10% checkedindependently by second reviewer.Agreement: 83%.Uncertainties resolved by discussion.

Following training, one reviewer selected possiblyrelevant studies for inclusion.Quality check: Random sample of 30% checkedindependently 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:Drummond for economic evaluations [18, 19].Allocation concealment for RCTs.Disagreements resolved by discussion.

Data extraction Data extraction by one reviewer.Quality check: 100% checked for accuracy by a secondreviewer.Disagreements resolved by discussion.

Data extraction by one reviewer.Quality check: Random sample of 40% extractedindependently by second reviewer.Disagreements resolved by discussion.

Analysis Reviews/RCTs categorised according to the question(s)that they answered:• Does supported self-management reduce healthcareutilisation 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 primaryoutcome (healthcare utilisation).Narrative synthesis within categories.

Meta-analysis: Standardised mean differences (randomeffects model) to examine the effects of self-management support interventions on hospitalisationrates, A&E attendances, quality of life and total costs.Permutation plots of the data from trials reporting bothutilisation (hospitalisation rates, A&E attendances ortotal 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 servicesfor people with LTCs.

A&E accident and emergency, LTC long-term condition, R-AMSTAR Revised Assessment of Multiple Systematic Reviews, RCT randomised controlled trial

Pinnock et al. BMC Medicine (2017) 15:64 Page 4 of 32

Extraction of dataData for the PRISMS review were extracted by HLP andLD (update) using a piloted data extraction form, andchecked independently by HP for integrity and accuracy.Disagreements were resolved by team discussion. Weextracted data on review rationale, the self-managementintervention under review, review methodology, summarydetails of included RCTs (participant demographics, com-parison groups, settings, service arrangements, compo-nents, duration/intensity of the intervention, follow-uparrangements) and the results of meta-analyses and narra-tive syntheses. We extracted the findings and conclusionsas synthesised by the authors of the systematic reviews,specifically avoiding going back to the individual primarystudies. The RCTs in the update review were extractedusing similar headings.A piloted data extraction sheet was devised for RE-

CURSIVE that included descriptive data (characteristicsof studies, populations and interventions) and quantita-tive data (for use in meta-analyses). All the descriptivedata and approximately 40% of the quantitative datawere double-extracted by two members of the researchteam working independently.

Data analysisMeta-analysis is inappropriate at the meta-review levelowing to the overlap of included RCTs between reviews.However, for the primary outcome, where two or moresystematic reviews (including the RECURSIVE meta-analyses) present pooled statistics, we displayed theresults graphically by creating ‘meta-Forest plots’. Weundertook narrative syntheses to answer our key ques-tions: Does supported self-management reduce use ofhealthcare resources and improve asthma control? Forwhich target groups does it work? Which componentscontribute to effectiveness? and In what contexts doessupported self-management work? We categorised thereviews and RCTs included in the PRISMS meta-reviewaccording to the question(s) that they answered (seeTables 3 and 4: column 3) and synthesised the findingswithin these categories.th=tlb=The final question (What is the effect of self-

management on healthcare utilisation and costs?) wasanswered by a meta-analysis of the RECURSIVE RCTdata. The primary analysis explored whether self-management support could reduce utilisation withoutcompromising outcomes. Standardised mean differences(SMD) were computed using a random effects modelmeta-analysis due to anticipated heterogeneity. Fourmeta-analyses examined the effects of self-managementsupport interventions on hospitalisation rates, A&Eattendances, quality of life and total costs, respectively.We then constructed permutation plots of the data fromthe subset of trials reporting both utilisation (hospitalisation

rates, A&E attendances or total costs) and health outcomes(quality of life). Further details about the analytic approachare described in the RECURSIVE report [14]. Forest plotsand permutation plots [21] for the subset of studies report-ing both health outcomes and utilisation outcomes wereconstructed in STATA version 14.

Interpretation and end-of-project workshopThe PRISMS and RECURSIVE teams worked independ-ently, but held regular teleconferences to enable synergiesbetween the findings of the parallel reviews to be devel-oped. Frequent meetings of the multidisciplinary teamsaided interpretation of the emerging findings. Finally, weheld an end-of-project stakeholder conference at whichthe findings and over-arching conclusions from PRISMSand RECURSIVE were presented to 34 multidisciplinarystakeholders, including people with LTCs, clinicians, com-missioners, providers of healthcare services and policy-makers. Small discussion groups discussed and advised onpractical implications for commissioning and providingservices for people with LTCs.

Lay involvementThe PRISMS project (which reviewed evidence from 14LTCs) benefited from a lay collaborator who was involvedfrom the inception of the project. She and other lay repre-sentatives from a range of LTC interest groups (includingAsthma UK) contributed to an initial stakeholder work-shop at which the choice of LTCs studied in the projectand self-management interventions of interest werediscussed. Lay members also participated in the end-of-project workshop (described above), which aidedinterpretation and guided dissemination. The PRIMERpatient and public involvement group at the University ofManchester, UK, collaborated with the RECURSIVEproject.

Updating of searches prior to publicationWe updated our PRISMS searches in January 2017 byundertaking forward citation of the original included re-views using Web of Science. Forward citation has beenshown to be an efficient and effective method of identi-fying relevant papers in systematic reviews of complexand heterogeneous evidence [22]. We considered it wasvery unlikely that a subsequent systematic review orRCT would be published without citing at least one ofthe previously published reviews. One reviewer (HP)undertook focused data extraction of key findings, whichwere checked by MP. The additional data were addedinto the syntheses as appropriate. Had we identifiedstudies that substantially changed our conclusions weplanned to undertake full duplicate data extraction,quality assessment and revise our synthesis.

Pinnock et al. BMC Medicine (2017) 15:64 Page 5 of 32

Table

3Summarytableof

finding

sof

PRISMSsystem

aticreview

sandtheirrelevanceto

themeta-review

questio

ns

Referenceand

weigh

ting*;RCTs,n

;Participants,n;R-

AMSTAR;Daterang

eof

includ

edRC

Ts

Com

parison

Relevanceto

meta-

review

questio

ns:

Interven

tions

includ

edTarget

grou

p(s)

Synthe

sis

Mainresults

Whatistheim

pact?

Target

grou

ps?

Which

compo

nents?

Con

text?

Bailey2009

[25]**

4RC

Ts617participants

R-AMSTAR36

RCTs

2000–2008

Culturally

orientated

prog

rammes

vs.usualcare

orlim

ited/

gene

riced

ucation.

FU(m

ode):12mo,rang

e4–12

mo

Impact

Target:Ethnicgrou

psEducation,actio

nplans,trigge

rsand

avoidance,

collabo

ratio

nwith

healthcare

services.

Lang

uage

-app

ropriate

asthmaed

ucators.

Minority

grou

ps:

Puerto

Rican,African-

American,H

ispanic,

Indian

sub-continen

t.Adu

ltsandchildren.

Meta-analysis

Narrativeanalysis

Redu

cedho

spitalisationin

children

(RR0.32,95%

CI0.15–0.70;1

RCT)

butno

trepo

rted

inadults.

Improved

QoL

inadults(W

MD0.25,

95%

CI0.09–0.41;2

RCTs).

2of

2RC

Tsrepo

rted

aredu

ctionin

A&E

visitsandho

spitalisations:one

repo

rted

nodifferencein

‘use

ofhe

althcare

resources’;2of

3repo

rted

improved

QoL

(adu

lts).

Bernard-Bo

nnin

1995

[26]**

11RC

Ts1290

participants

R-AMSTAR27

RCTs

1981–1991

Interactiveteaching

onself-managem

ent

vs.stand

ardcare.

Impact

Target:C

hildren

Interactiveteaching

(one

-to-on

eor

grou

p)to

supp

ortasthma

self-managem

ent.

Children1–18

y.Overallseverity

classifiedas

‘mild

tomod

erate’.

Meta-analysis

Narrativeanalysis

Redu

cedho

spitalisation(ES0.06

±−0.08)andem

erge

ncyvisits

(ES0.14

±0.09);5RC

Ts.

Childrenwith

high

baselinenu

mbe

rsof

hospitalisations

andem

erge

ncy

visitshadgreatestsubseq

uent

redu

ctionin

morbidity.

Bhog

al2006

[23]**

4RC

Ts355participants

R-AMSTAR41

RCTs

1990–2004

Symptom

-based

written

PAAPs

vs.p

eakflow-based

PAAP.

FU(m

ode):3

mo,rang

e3–24

mo

Target:C

hildren

Com

pone

nts:PEFvs.

symptom

mon

itorin

g

Asthm

aed

ucation

plus

PAAPs

forbo

thparentsandchildren.

Gen

erallycontaine

d3

step

s:often

employing‘traffic

lights’.

Mon

itorin

gvaried:

either

daily

orwhe

nsymptom

atic.

Children6–19

ywith

mild

tosevere

asthma.

Meta-analysis

Symptom

-based

PAAPs

redu

ced

unsche

duledcare

comparedto

peak

flow-based

PAAPs

(RR0.73,95%

CI

0.55–0.99;4RC

Ts).

Nodifferencein

hospitaladm

ission

s(RR1.51,95%

CI0.35–6.65.

Peak

flow-based

PAAPs

redu

cedthe

numbe

rof

symptom

aticdays/w

eek

(MD0.45

days/w

eek,95%

CI0.04–

0.26;2

RCTs).Nosign

ificant

differ-

ence

foradultor

child

QoL.

Zemek

2008

[24]**

5RC

Ts423participants

R-AMSTAR41

RCTs

1990–2005

WrittenPA

APs

vs.noPA

AP.

Symptom

-based

vs.

PEF-basedPA

AP.

FU(m

ode):3

mo,rang

e0.5–24

mo

Impact:

Target:C

hildren

Com

pone

nts:PA

AP

Educationforparents

andchildren,plus

PAAPs,w

ith3step

s:oftenem

ploying

‘traffic

lights’.

Mon

itorin

gvaried:

either

daily

orwhe

nsymptom

atic.

Scho

ol-age

dchildren

with

mild

tosevere

asthma.

Meta-analysis

APEF-basedPA

APredu

ced

unsche

duledcare

comparedto

noplan

(WMD−0.50,95%

CI−

0.83

to−0.17;1

RCT).

APEF-basedPA

APcomparedto

noplan

redu

cedsymptom

scores

(WMD

−11.80,95%

CI−

18.22to

−5.38)and

numbe

rof

scho

oldays

missed

(WMD−1.03,95%

CI−

1.85

to−0.21;

1RC

T).

Boyd

2009

[27]***

38RC

Ts7843

participants

R-AMSTAR39

RCTs

1985–2007

Educationtargeting

children/parents

vs.low

intensity

education.

Impact:

Target:C

hildren,A&E

attend

ees

Educationplus

therapyreview

,self-

mon

itorin

g,PA

APs,

andtrigge

ravoidance.

Children0–18

ywho

hadattend

edA&E

for

asthmawith

inthe

previous

12mo.

Meta-analysis

Subg

roup

analyses

Educationredu

cedA&E

attend

ances

(RR0.73,95%

CI0.65–0.81;17RC

Ts),

admission

s(RR0.79,95%

CI0.69–

0.92;18RC

Ts)andun

sche

duled

Pinnock et al. BMC Medicine (2017) 15:64 Page 6 of 32

Table

3Summarytableof

finding

sof

PRISMSsystem

aticreview

sandtheirrelevanceto

themeta-review

questio

ns(Con

tinued)

FU(m

ode):12morang

e4–12

mo

Rang

eof

settings

and

profession

alsand

mod

eof

delivery.

consultatio

ns(RR0.68,95%

CI0.57–

0.81;7

RCTs).

Noeffect

onQoL

(WMD0.13,95%

CI

0.73–0.99;2RC

Ts).

Subg

roup

analyses

(typeandtim

ing

ofinterven

tion,tim

ingof

outcom

eassessmen

tor

ageof

participants)

didno

tchange

finding

s.

Bussey

Smith

2009

[28]*

9RC

Ts957participants

R-AMSTAR26

RCTs

1986

-2005

Com

puterised

education

vs.traditio

nalself-

managem

ent

FU(m

ode):12mo,rang

e3–12

mo

Impact:

Com

pone

nts:

Techno

logy-based

interven

tions

Interactive

compu

terised

educationalasthm

aprog

rammes

(gam

estailoredto

the

individu

al,w

eb-based

education,interactive

commun

ication

devices).

Patients3–75

y.7RC

Tsin

children,

2in

adults;4

RCTs

inurbanor

inne

r-city

popu

latio

ns.

Narrativeanalysis

1of

4im

proved

hospitalisation,and

1of

5redu

cedun

sche

duledcare.

5of

9stud

iesfoun

dstatistical

improvem

entsin

asthmasymptom

scomparedto

control.

Chang

2010

[29]**

1RC

T113participants

R-AMSTAR40

RCT2010

Educationby

IHWs

vs.edu

catio

nno

IHW.

FU:12mo

Impact:

Target:Ethnicgrou

psInitialclinical

consultatio

n,reinforced

byho

me

visitsfro

matraine

dIHW.Personalised,

child-friend

ly,culturally

approp

riate

education

materials.

African-American

and

Hispanic

commun

ities.

Children1–17

y;mean~7y.

Narrativeanalysis

Therewas

noeffect

onho

spitalisations

(OR1.58,95%

CI

0.37–6.79)

orA&E

attend

ances(OR

0.30,95%

CI−

0.17

to0.77;1

RCT).

Daysabsent

from

scho

olwere

redu

cedby

21%

intheinterven

tion

grou

p(95%

CI5–36%

;1RC

T).

Carer

asthmaQoL

was

not

sign

ificantlydifferent

(MD0.25,95%

CI−

0.39

to0.89).

Coffm

an2009

[30]**

18asthmaRC

Ts8077

participants

R-AMSTAR29

RCTs

1987-2007

Scho

ol-based

asthma

educationvs.usualcare.

Impact:

Target:Schoo

lchildren

Scho

ol-based

educationon

asthma,

med

ication,

mon

itorin

g,avoiding

trigge

rs.D

elivered

bynu

rses,health

educators,pe

ercoun

sellors,teachers,

±compu

ter

prog

rammes.

Children4–17

y.Severity:mild

tosevere,m

ajority

were

Blackor

Latin

o.

Narrativeanalysis

Unsched

uled

healthcare

was

not

repo

rted

.Scho

olabsences

sign

ificantly

redu

cedin

5of

13RC

Ts.D

ayswith

symptom

swereredu

cedin

3of

8RC

Ts.N

ightswith

symptom

sim

proved

in1of

4RC

Ts:1

foun

dim

provem

entin

thecontrolg

roup

.QoL

improved

in4of

6RC

Ts.

Gibson2002

[31]***

36RC

Ts6090

participants

R-AMSTAR39

RCTs

1986

–2001

Self-managem

ent

prog

rammes

vs.usualcare.

Impact:

Com

pone

nts:Regu

lar

review

Con

text:LTC

care

Education(100%);

self-mon

itorin

gof

symptom

sor

PEF

(92%

);regu

larreview

byamed

icalpracti-

tione

r(67%

);PA

AP

(50%

).Subg

roup

analyses

basedon

theseservicemod

els.

Adu

ltsandchildren.

Rang

eof

settings,

includ

ingho

spital,

emerge

ncyroom

,ou

tpatients,

commun

itysetting,

gene

ralp

ractice.

Meta-analysis

Subg

roup

analysis

Self-managem

entredu

ced

hospitalisations

(RR0.64,95%

CI

0.50–0.82;12

RCTs),A&E

visits(RR

0.82,95%

CI0.73–0.94;13RC

Ts]and

unsche

duledconsultatio

ns(RR0.68,

95%

CI0.56–0.81;7

RCTs).

Self-managem

entredu

ceddays

off

work/scho

ol(RR0.79,95%

CI0.67–

0.93;7

RCTs)andim

proved

QoL

(SMD0.29,95%

CI0.11–0.47;6

RCTs).

Optim

alself-managem

ent(sup

-po

rted

byaPA

APandregu

lar

Pinnock et al. BMC Medicine (2017) 15:64 Page 7 of 32

Table

3Summarytableof

finding

sof

PRISMSsystem

aticreview

sandtheirrelevanceto

themeta-review

questio

ns(Con

tinued)

review

)redu

cedho

spitalisations

(RR

0.58,95%

CI0.43–0.77;9

RCTs),and

A&E

visits(RR0.78,95%

CI0.67–0.91;

9RC

Ts).

Gibson2004

[32]***

26RC

Ts6090

participants

R-AMSTAR39

RCTs

1987–2002

Differen

tcompo

nents

ofwrittenPA

APs

vs.usualcare.

Com

pone

nts:PA

APs

Com

pletePA

APs

specified

whe

n/ho

wto

increase

treatm

ent

(n=17);incomplete

omitted

advice

onincreasing

ICS(n=4);

non-specific(n=5)

onlyhadge

neral

instructions.

Adu

ltsandchildren.

Variety

ofsettings,

includ

ingho

spital,

emerge

ncyroom

,ou

tpatients,

commun

itysetting,

gene

ralp

ractice.

Actionpo

ints

%pred

ictedvs.%

best

Treatm

entadvice

Non

-spe

cific

plans

Bene

fitswerefoun

dforanynu

mbe

rof

actio

npo

ints(2

to4).

Both

%pred

ictedand%

best

redu

cedho

spitalisations,b

uton

ly%

person

albe

stredu

cedA&E

visits.

PAAPs

which

includ

edadvice

onincreasing

ICSandstartin

goral

steroids

redu

cedho

spitalisations

and

A&E

visits.

Efficacyof

incompleteandno

n-specificPA

APs

was

inconclusive.

Mou

llec2012

[33]**

18RC

Ts3006

participants

R-AMSTAR27

RCTs

1990–2010

Interven

tions

toim

prove

inhaledsteroidadhe

rence

vs.usualcare.

FU(m

ode):12mo,rang

e0.25–24mo

Con

text:LTC

care

Allstud

iesinclud

edself-managem

ent;

someinclud

edcom-

pone

ntsof

CCM:deci-

sion

supp

ort,de

livery

system

design

,clinical

inform

ationsystem

s.

Mod

erateto

severe

asthma(one

RCT

includ

edCOPD

).Age

d35–50y.Wom

enover-rep

resented

.

Meta-analysis

Effect

size

foradhe

renceto

ICS

comparedby

numbe

rof

compo

nentsof

theCCM

inthe

stud

y:1CCM

compo

nent

(n=13):sm

allES

0.29

(95%

CI0.16–0.42)

2CCM

compo

nents(n=5):large

ES0.53

(95%

CI0.40–0.66)

3CCM

compo

nents(nostud

ies)

4CCM

compo

nents(n=4)

very

largeES

0.83

(95%

CI0.69–0.98).

New

man

2004

[34]**

18asthmaRC

Ts(of6

3RC

Ts)

2004

participants

R-AMSTAR23

RCTs

1997

–2002

Self-managem

ent

interven

tions

vs.stand

ardcare/basic

inform

ation.

Impact:

Individu

al/group

interven

tions,focused

onsymptom

mon

itorin

g,trigge

ravoidanceand

adhe

renceto

med

ication.Afew

used

techniqu

esto

addressbarriersto

effectiveself-

managem

ent.

Adu

ltswith

3LTCs

(includ

ingasthma).

Narrativeanalysis

andcomparison

betw

een

interven

tions

7of

11stud

iesrepo

rted

aredu

ction

inun

sche

duledhe

althcare.

6of

12stud

iesrepo

rted

improved

QoL.

3of

8stud

iesrepo

rted

redu

ctions

inseverityof

symptom

s,allu

sed

educationandactio

nplans.

8of

14repo

rted

improved

adhe

rence.

Postma2009

[35]**

7RC

Ts2316

participants

R-AMSTAR23

RCTs

2004–2008

CHWs

vs.usualcare.

FU(m

ode):12mo,

rang

e4–24

mo

Impact:

Target:Ethnicgrou

ps,

children

CHWsfro

mthesame

commun

ityas

participants.

Educationon

asthma,

lifestyleandtrigge

ravoidance,with

resourcesto

redu

ceallergen

expo

sure.

Children5–9ywith

allergiesandlow-

income.Mainly

African-American

and

Hispanic.

Narrativereview

3of

6stud

iesrepo

rted

redu

ced

hospitalisationandredu

ced

unsche

duledconsultatio

ns.

4of

6repo

rted

redu

cedA&E

attend

ances

‘Con

sisten

tandsign

ificant

decrease

incaregiver-repo

rted

asthmasymp-

tomsam

onginterven

tionsubjects

comparedwith

controlsub

jectsin

6stud

ies.’

Powell2009[36]***

15RC

TsCom

pone

nts:PA

AP,

regu

larreview

Self-

vs.p

hysician

adjustmen

tof

Adu

ltswith

asthma

recruitedfro

ma

Self-

vs.p

hysician

managem

ent

Of6stud

ies:4repo

rted

nodifferencein

hospitalisation,1

Pinnock et al. BMC Medicine (2017) 15:64 Page 8 of 32

Table

3Summarytableof

finding

sof

PRISMSsystem

aticreview

sandtheirrelevanceto

themeta-review

questio

ns(Con

tinued)

2460

participants

R-AMSTAR34

RCTs

1990–2001

Self-managem

entvs.

physician-review

edmanagem

ent.

Com

parison

ofmod

ified

PAAPs.

Con

text:LTC

care

med

ication

(n=6stud

ies).

PEFvs.sym

ptom

sPA

APs

(n=6).

Other

variatio

ns(n=3).

rang

eof

prim

ary,

commun

ity,A

&Eand

second

arycare.

Symptom

svs.PEF-

mod

ified

PAAPs

repo

rted

nodifferencein

A&E

visits,

3repo

rted

inconsistent

effectson

unsche

duledconsultatio

ns.

Of6stud

ies,6repo

rted

nodifferencein

hospitalisation,5

repo

rted

inconsistent

effectson

A&E

visits.

Omittingregu

larreview

(1RC

T)or

redu

cing

intensity

ofed

ucation

(1RC

T)increasedun

sche

duled

consultatio

ns.Verbal(vs.w

ritten)

PAAPs

hadno

effect

onho

spitalisations

orA&E

visits(1

RCT).

Ring

2007

[37]***

14RC

Ts4588

participants

R-AMSTAR35

RCTs

1993–2005

Interven

tions

encouraginguseof

PAAPs

vs.usualcare.

Con

text:O

rganisation

ofcare

Interven

tions

prom

otingPA

AP

owne

rshipor

use.

Diverse

interven

tions

(edu

catio

nal,

prom

pting,

asthma

clinics,asthma

managem

entsystem

s,qu

ality

improvem

ent).

Adu

ltsor

children

with

mod

erateto

severe

asthma;some

post-exacerbation.

Narrativeanalysis

4of

5stud

iesof

education,1of

2stud

iesof

teleph

oneconsultatio

ns,1

of2stud

iesof

asthmaclinicsand1

of2stud

iesof

asthmamanagem

ent

system

srepo

rted

increasedPA

AP

owne

rship.

1stud

yof

self-managem

ente

ducation,

1of

2stud

iesof

teleph

oneconsulta-

tions

and1of

2stud

iesof

asthma

managem

entsystemsincreased

understand

ing/useof

PAAPs.

Tapp

2007

[38]***

13RC

Ts2157

participants

R-AMSTAR39

RCTs

1979–2009

Asthm

aed

ucation

atA&E

visit

vs.usualcare.

FU(m

ode):6

mo,

rang

e2–18

mo

Impact:

Target:PostA&E

attend

ance

Asthm

aed

ucation

provided

byasthma

orA&E

nurses

with

inaweekof

A&E

visit

includ

edPA

APs,

trigge

rs,m

onito

ring,

inhalersand

med

ication.

Adu

ltsrecruited

durin

gA&E

attend

ance.

Meta-analysis

Narrativeanalysis

Theinterven

tionredu

cedho

spital

admission

s(RR0.50,95%

CI0.27–

0.91;5

RCTs),A&E

visits(RR0.66,95%

CI0.41–1.07;8

RCTs).

Effect

onQoL

(2RC

Ts)w

asinconsistent.The

rewas

noeffect

ondays

offwork/scho

ol.

Toelle2004

[39]**

7RC

Ts967participants

R-AMSTAR38

RCTs

1990–2001

WrittenPA

AP

vs.noplan.

Symptom

vs.

PEF-basedPA

AP.

FU(m

ode):12mo,

rang

e6–12

mo

Com

pone

nts:PA

AP

Peak

flow-based

writtenPA

APor

symptom

-based

writtenPA

APde

liv-

ered

inprim

aryor

tertiary

care.

Adu

lts28–45yand

childrenin

1RC

T.Meta-analysis

Subg

roup

analysis

Unsched

uled

healthcare:assessedin

1RC

T,no

trepo

rted

bysystem

atic

review

.Nodifferencebe

tweensymptom

andpe

akflow-based

PAAPs

inho

spitalisations

(RR1.17,95%

CI

0.31–4.43;3RC

Ts)or

A&E

atten-

dances

(RR1.17,95%

CI0.31–4.43;3

RCTs).

Symptom

-based

PAAPs

weremore

effectiveat

redu

cing

unsche

duled

consultatio

ns(RR1.34,95%

CI

1.01–1.77;2RC

Ts).

Welsh

2011

[40]***

12RC

Ts2342

participants

R-AMSTAR41

Hom

e-based

self-managem

ent

vs.rou

tinecare

orge

neral

education.

Impact:

Target:C

hildren

Lang

uage

-app

ropriate

education(asthm

a,trigge

rs,m

edication,

inhalers,self-

Children(m

ostly

<12

y)recruitedfro

mrecent

healthcare

visit.

Mainlyethn

icand/or

Meta-analysis

Narrativeanalysis

Nodifferencebe

tweengrou

psin

meannu

mbe

rof

A&E

visits(M

D0.04,

95%

CI−

0.20

to0.27;2

RCTs).

Pinnock et al. BMC Medicine (2017) 15:64 Page 9 of 32

Table

3Summarytableof

finding

sof

PRISMSsystem

aticreview

sandtheirrelevanceto

themeta-review

questio

ns(Con

tinued)

RCTs

1986–2010

FU(m

ode):12mo,rang

e6–24

mo

managem

entwith

PAAPs).Alsoho

me-

work,techno

logy

de-

vices,24-hou

rho

tline

.

deprived

commun

ities

inUSA

.2of

5stud

iesrepo

rted

hospitalisation:on

efoun

da

redu

ctionandon

ean

increase

inthe

interven

tiongrou

p.Effect

onA&E

visits(6

RCTs)was

inconsistent.

Overallno

effect

onQoL

was

foun

din

5stud

ies.

Bravata2009

[41]***

63RC

Ts13,476

participants

R-AMSTAR40

RCTs

1966–2006

Self-managem

entQIvs.

othe

rQIstrateg

ies.

Impact:

Target:C

hildren

Self-mon

itorin

gor

self-managem

ent.Pa-

tient/careg

iver

educa-

tion.Provider

education.Organisa-

tionalchang

eandin-

terven

tions

with

multip

leQIstrateg

ies.

Children<18

y.Meta-analysis

Interven

tions

targetingparents/

caregiversredu

cedho

spitalisation

ratesby

1.2%

peryear

(95%

CI0.1–

2.4;n=5).

Self-managem

entinterven

tion

stud

iesim

proved

symptom

-free

days

by2.8%

(95%

CI0.6–5.0),which

equalled0.8days

permon

th(n=7);

andredu

cedmon

thlyscho

olabsen-

teeism

by0.4%

(95%

CI0–0.7),which

equalled0.1daype

rmon

th(n=16).

Long

erdu

ratio

nof

interven

tionin-

creasedtheeffect

onscho

olabsences.

Den

ford

2014

[43]***

38RC

Ts7883

participants

R-AMSTAR36

RCTs

1993–2000

Asthm

aself-care

vs.usual/le

ssintensive

interven

tion.

FU(m

ode):12mo,rang

e3–18

mo

Impact:

Com

pone

nts:

Behaviou

rchange

Com

mon

est

behaviou

ralchang

etechniqu

esinclud

ing:

self-mon

itorin

g(n=

30),instruction(n=

27),go

al-settin

g(n=

26)andinhalertech-

niqu

e(n=24).

Adu

lts≥18

ywith

adiagno

sisof

asthma.

Meta-analysis

Interven

tiongrou

pparticipantshad

redu

cedasthmasymptom

s(SMD

−0.38,95%

CI−

0.52

to0.24;27RC

Ts)

andun

sche

duledhe

althcare

use(OR

0.71,95%

CI0.56–0.9;23

RCTs).

Increasedadhe

renceto

preven

tative

med

icationcomparedto

control(OR

2.55,95%

CI2.11–3.10;16RC

Ts).

deJong

h2012

[42]**

1asthmaRC

T(of4)

16participants

R-AMSTAR35

RCTs

1993–2009

Mob

ileph

onemessaging

forself-

managem

entvs.

usualcare.

FU:range

4–12

mo

Com

pone

nts:Mob

ileph

onemessaging

Self-managem

ent

interven

tions

delivered

bymob

ileph

onemessaging

.

Participantsof

all

ages,g

ende

ror

ethn

icity.

Includ

edanyLTC

(one

asthmastud

y).

Narrativesynthe

sis

Inthesing

leasthmastud

y,there

werefewer

admission

s(2

vs.7)bu

tmoreun

sche

duledconsultatio

ns(21

vs.15)

intheinterven

tiongrou

pcomparedto

theusualcaregrou

p.Thepo

oled

asthmasymptom

score

show

edasign

ificant

difference

betw

eengrou

ps,favou

ringthe

interven

tiongrou

p(M

D−0.36,95%

CI−

0.56

to−0.17).

Kirk

2012

[44]**

10asthmaRC

Ts2195

participants

R-AMSTAR23

RCTs

1995–2010

Self-care

supp

ort

vs.usualcare.

FU(m

ode):12mo,rang

e3–24

mo

Impact:

Target:C

hildren

Interven

tions

aiming

tohe

lpchildrentake

controlo

fand

managetheir

cond

ition

,promote

theircapacity

forself-

care

and/or

improve

theirhe

alth.

Children≤18

ywith

aLTC:

asthma(10RC

Ts),

cysticfib

rosis(2)or

diabetes

(1).

Narrativesynthe

sis

Of8RC

Ts,2

repo

rted

fewer

asthma

admission

s,5repo

rted

fewer

A&E

attend

ancesand2of

3repo

rted

fewer

unsche

duledconsultatio

ns.

Con

trol

improved

in5of

8RC

Ts.

Qol

improved

in2of

5RC

Ts.

Marcano

Belisario

2013

[45]**

Self-managem

entapps

Com

pone

nts:

Smartpho

neApp

sSelf-managem

ent

supp

ortinterven

tions

Adu

ltswith

clinician-

diagno

sedasthma.

Narrativesynthe

sis

Of2RC

Ts,2

repo

rted

nodifference

inho

spitaladm

ission

s;1repo

rted

Pinnock et al. BMC Medicine (2017) 15:64 Page 10 of 32

Table

3Summarytableof

finding

sof

PRISMSsystem

aticreview

sandtheirrelevanceto

themeta-review

questio

ns(Con

tinued)

2RC

Ts408participants

R-AMSTAR39

RCTs

2000–2013

vs.traditio

nalself-

managem

ent.

FU:6

mo

provided

bysm

artpho

neapp.

fewer

A&E

attend

ancescomparedto

control;1foun

dno

differencein

unsche

duledGPconsultatio

nsor

out

ofho

ursconsultatio

ns,b

utredu

ced

prim

arycare

nurseconsultatio

ns;1

repo

rted

nodifferencein

MDin

Asthm

aCon

trol

Questionn

aire

scores

betw

eentheinterven

tionand

controlg

roup

at6mon

ths;1foun

dim

proved

QoL

intheinterven

tion

grou

p.

Press2012

[46]***

5RC

Ts(of15

stud

ies)

1459

participants

R-AMSTAR34

RCTs

1950–2010

Interven

tions

targeted

atethn

icminority

grou

psvs.usualcare.

FU(m

ode):6

mo,rang

e0.25–32mo

Impact:

Target:Ethnic

grou

ps

Interven

tions

targetingethn

icpo

pulatio

nsin

US.15

wereed

ucation-

based,

9weresystem

-levelinterventions,5

werecultu

rally

tai-

loredand

commun

ity-based

,10

wereho

spital-b

ased

.

Adu

lts≥18

y.Ethn

icminority

grou

ps:

African-Americans

(10stud

ies,Latin

os(4

stud

ies).

Narrativesynthe

sis

Aned

ucationinterven

tionredu

ced

A&E

attend

ance

in2of

4RC

Tsand

hospitaladm

ission

sin

2of

3RC

Ts.

Symptom

swereno

tredu

cedin

any

ofthe3RC

Tsthat

measuredcontrol.

QoL

was

improved

in3of

4RC

Tsthat

used

anasthma-relatedQoL

outcom

e.

Stinson2009

[47]*

4asthmaRC

Ts(of9

stud

ies)

826asthma

participants

R-AMSTAR28

RCTs

1993–2008

Internet-based

self-

managem

entvs.usual

care.

FU(m

ode):12mo,rang

e3–12

mo

Target:C

hildren

Com

pone

nts:

Internet-based

Any

Internet-based

oren

abledself-

managem

ent

interven

tion.

Children6–12

yor

adolescents13–18y

with

LTCs:asthm

a(4

RCTs),pain

(1),

encopresis(1),brain

injury

(1)or

obesity

(1).

Narrativesynthe

sis

1RC

Trepo

rted

nodifferencein

hospitalisations

comparedto

control,

1RC

Trepo

rted

sign

ificant

redu

ctions

inA&E

visitsand1of

2RC

Tsshow

edfewer

unsche

duledconsultatio

ns.

4ou

tof

4repo

rted

sign

ificant

improvem

entin

ameasure

ofcontrol.

1of

4asthmaRC

Tsrepo

rted

asign

ificant

bene

fiton

QoL.

Abb

reviations:A

&Eaccide

ntan

dem

erge

ncy,CC

Mchroniccare

mod

el,C

HW

commun

ityhe

alth

workers,C

Icon

fiden

ceinterval,C

OPD

chronicob

structivepu

lmon

arydisease,

ESeffect

size,FUfollow-up,

ICSinha

led

corticosteroid,IHW

indige

nous

healthcare

workers,LTC

long

-term

cond

ition

,MDmeandifferen

ce,m

omon

ths,ORod

dsratio

,PAAPpe

rson

alised

asthmaactio

nplan

,PEF

peak

expiratory

flow,Q

Iqua

lityim

prov

emen

t,QoL

quality

oflife,

RRriskratio

,SMDstan

dardised

meandifferen

ce,W

MDweigh

tedmeandifferen

ce,y

years

Pinnock et al. BMC Medicine (2017) 15:64 Page 11 of 32

Table

4Summarytableof

finding

sof

update

rand

omised

controlledtrialsandtheirrelevanceto

themeta-review

questio

nsReferenceandweigh

ting;

Participants,n

;Riskof

bias

Com

parison

Relevanceto

meta-review

questio

ns:

Stud

ytype

and

interven

tions

includ

edTarget

grou

p(s)

Mainresults

[1o]isthede

fined

prim

aryou

tcom

e

Whatistheim

pact?

Target

grou

ps?

Which

compo

nents?

Con

text?

Al-She

yab2012

[48]

n=261

HIGHriskof

bias

Ado

lescen

tAsthm

aActionprog

rammevs.

standard

care.

FU:3

mo

Target:A

dolescen

tsCom

pone

nts:Peer

education

Cluster

RCT.

TripleA.Peerleadersfro

myear

11weretraine

dto

deliver

prog

rammeto

years8,9and10.

Ado

lescen

tsin

Jordanian

high

scho

ol.Igrou

phad

fewer

females,few

ersymptom

sandhigh

erEnglishproficiency.

Com

paredto

controlimprovem

ents

QoL

scoreim

proved

[I:5.42

(SD0.14)

vsC:4.07(SD0.14)MD1.35

(95%

CI

1.04–1.76)].

Baptist2013

[49]

n=70

HIGHriskof

bias

Person

alised

asthma

self-regu

latio

ninter-

ventionvs.edu

catio

nsession.

FU12

mo

Target:O

lder

adults

Com

pone

nts:Health

educator

RCT.

6-sessionprog

ramme

(group

teleph

one).

Patientsselected

anasthma-specificgo

al,and

addressedpo

tential

barriers.

Con

trol

issing

lesession

basiced

ucation+2

teleph

onecalls.

Age

d≥65

y.Ph

ysician

diagno

sisof

asthma,no

restrictio

nin

severity.

Majority

Caucasian.

Nobe

tween-grou

pdifferences

inA&E

visitsor

hospitalisations.H

ealth

care

utilisatio

nwas

lower

at6mobu

tno

t12

mo.ACQwas

similarat

1moand

6mo.At12

mo,Ip

articipantswere

4.2tim

esmorelikelyto

have

anACQ

score<0.75.

[1o]QoL

(mAQLQ

)was

sign

ificantly

high

erin

theIthanin

Cat

alltim

epo

ints(1,6

and12

mo).

Ducharm

e2011

[50]

n=219

LOW

riskof

bias

‘Take-ho

meplan’p

ost

A&E

visitwith

PAAP+

prescriptio

ninform

ationvs.

prescriptio

nbu

tno

PAAP/inform

ation.

FU:28days

Target:C

hildren,

A&E

attend

ees

Com

pone

nts:PA

APwith

prescriptio

n

RCT.

Interven

tioniswritten

PAAPwith

a‘form

atted’

prescriptio

nforICS(i.e.

includ

inginform

ation

abou

tuse)

issued

byA&E

doctor

ondischarge

followingasthma

exacerbatio

n.

Canadianchildren1–17

yrecruiteddu

ringA&E

attend

ance

foracute

asthma(78%

wereun

der

theageof

6y).

Nobe

tween-grou

pdifferences

inun

sche

duledcare

at28

days.C

om-

paredto

control,at

28days

children

giventhePA

APhadbe

tter

asthma

control(prop

ortio

nwith

Asthm

aQuiz

Score<2I:58%

vs.C

:41%

;RR1.36,

95%

CI1.04–1.86).

Nobe

tween-grou

pdifferences

inchild/careg

iver

QoL

at28

days.

[1o]Adh

eren

ceto

ICSde

clined

from

90%

(day

1)to

50%

atday14,w

ithno

sign

ificant

grou

pdifference.

Goe

man

2013

[51]

n=114

Low

riskof

bias

Person

-cen

tred

educationvs.w

ritten

inform

ation.

FU:12mo

Target:O

lder

adults

Com

pone

nts:Person

alised

education

RCT.

Person

allytailored

educationsessionwith

asthmaed

ucator

basedon

respon

sesto

aqu

estio

nnaire;inh

aler

techniqu

e.

≥55

y,commun

ity-based

asthmaticswith

norestric-

tionin

asthmaseverity.

[1o]At12

moIp

articipantshadbe

tter

asthmacontrolthanC(ACQMD0.3,

95%

CI0.06–0.5,p=0.01)andbe

tter

asthma-relatedQoL

(p=0.01).

Nosign

ificant

differencein

numbe

rof

steroidcourses(p=0.17).

At12

mo,moreIp

articipants(n=36,

61%)ow

nedaPA

APcomparedto

C(n=21,38%

;p=0.015).

[1o]Similaradhe

renceto

ICSat

12mo

(p=0.015).

Halterm

an2014

[52]

n=638

LOW

riskof

bias

Person

alised

prom

pts

forclinicians

and

parents,practice

training

andfeed

back

vs.w

rittengu

idelines.

FU:6

mo

Target:C

hildren,

deprived

commun

ities

Com

pone

nts:Feed

back

Con

text:C

ommun

ity-

based,

clinicaltraining

Cluster

RCT.

Interven

tionpractices

received

person

alised

clinicianandparent

prom

pts+blankPA

AP;

practicetraining

;feedb

ack.

Con

trol

practices

sent

guidelines.

Urban,p

rimarycare

practices

inde

prived

commun

ities.

Parents/children2–12

ywith

persistent,p

oorly

controlledasthma.

Recruitedfro

mwaitin

groom

over

4ystudy.

11%

inbo

thgrou

pshadan

A&E

visit

orho

spitalisation.

[1o]Com

paredto

controlp

ractices,at

2mochildrenin

thePA

IR-UPpractices

hadmoresymptom

-free

days

[I:10.2days/2

weeks

(SD4.8)

vs.

C:9.5days/2

weeks

(SD5.1);M

D0.78,

95%

CI0.29–1.27]bu

tthedifference

was

notsign

ificant

at6mo.

Nightswith

symptom

sremaine

dsign

ificant

at6mo[I:1.4(SD3.0)

vs.

Pinnock et al. BMC Medicine (2017) 15:64 Page 12 of 32

Table

4Summarytableof

finding

sof

update

rand

omised

controlledtrialsandtheirrelevanceto

themeta-review

questio

ns(Con

tinued)

C:1.8(SD3.2);M

D−0.43;95%

CI

−0.77

to−0.09].

Horne

r2014

[53]

n=183

UNCLEARriskof

bias

Asthm

aplan

forkids

vs.teachingon

gene

ralh

ealth

and

well-b

eing

.FU

:12mo

Target:C

hildren,

rural

commun

ities

Cluster

RCT.

Prog

rammede

livered

in16

×15

min

sessions,

3days/w

eekfor5.5weeks,

byscho

olnu

rses

durin

glunchbreak+ho

mevisit.

Grade

s2–5(age

s7–11

y)with

physiciandiagno

sisof

asthma.

Nobe

tween-grou

pdifferencefor

admission

sor

A&E

visits.

Nobe

tween-grou

pdifferencein

QoL

scores.

Inhalerskillim

proved

inthe

interven

tiongrou

pcomparedto

controlafter

4mo,with

repo

rted

high

erself-efficacy.

Joseph

2013

[54]

n=422

UNCLEARriskof

bias

Web

-based

asthma

managem

ent

interven

tionvs.

control.

FU:12mo

Target:A

dolescen

ts,urban

deprived

,ethnicgrou

psCom

pone

nts:Web

-based

,be

haviou

ralchang

e

RCT.

Internet-based

prog

ramme

targeted

atAfrican-

Americans/urban

adolescentswith

traits

(low

motivation;

low

perceivedem

otional

supp

ort;resistance

tochange

;reb

elliousne

ss).

Grade

s9–12

(age

s14–18

y)with

physiciandiagno

sis

ofasthmaandrepo

rt>4days

ofrestricted

activity

inthepast30

days

atbaseline.

Nodifferencein

repo

rted

A&E

visits/

hospitalisations

at12

mo.

[1o]Com

paredto

C,at12

motheI

participantshadfewer

symptom

-days

(RR0.8,95%

CI0.6–1.0).

Nodifferencein

nigh

tswith

symptom

s,scho

oldays

missed,

days

ofrestrictedactivity

ordays

hadto

change

plans.

Stud

entscharacterised

with

rebe

lliou

snessor

low

perceived

emotionalsup

portrepo

rted

fewer

symptom

-days.

Khan

2014

[55]

n=91

HIGHriskof

bias

Asthm

aed

ucation+

individu

alised

written

PAAPvs.asthm

aed

ucation(excluding

PAAP).

Target:Ethnicgrou

psCom

pone

nts:Written

PAAP

RCT.

Both

grou

psreceived

individu

alasthma

educationdu

ringan

OPD

visitfro

mapaed

iatrician+

mon

thlyFU

.Intervention

grou

ptraine

din

usinga

PAAP.

1–14

y.RecruitedviaA&E

OPD

with

partlycontrolled

asthma(daytim

eor

nocturnalsym

ptom

s,activity

limitatio

n,lung

functio

n<0%

bestor

exacerbatio

nin

previous

year).

[1o]Tren

dforim

proved

outcom

esat

6mobu

tno

sign

ificant

betw

een-

grou

pdifferencein

prop

ortio

nof

childrenattend

ingA&E

(I:36%

vs.

C:52%

;p=0.141).

Therewas

nobe

tween-grou

pdifferencein

unsche

duleddo

ctor

visits,asthm

aattacks,missedscho

oldays

ornigh

t-tim

eaw

aken

ings.

Rhee

2011

[56]

n=112

UNCLEARriskof

bias

Peer-ledasthma

educationprovided

bype

ersat

adaycamp

vs.adu

lt-ledcamp.

Target:A

dolescen

ts.

Com

pone

nts:Peer

leaders

RCT.

Asthm

aself-managem

ent

skills+psycho

socialskills

taug

htat

adaycampby

peer

leaders+mon

thly

peer

teleph

onecontact.

Con

trol:Sim

ilared

ucation

delivered

byadults.N

oteleph

one.

13–17y(includ

inglow-

incomefamilies).Mild/

mod

erate/severe

asthma.

Asthm

adiagno

sisfor1y.

Ableto

unde

rstand

spoken

andwritten

English.

[1o]Bo

thgrou

psrepo

rted

sign

ificantly

increasedQoL

over

time(F=4.31,

p=0.002),w

ithIg

roup

having

sign

ificantlyhigh

erQoL

at6mo(M

D11.38,95%

CI0.96–21.79,p=0.03)and

9mo(M

D12.97,95%

CI3.46–22.48,p

=0.008).

Both

grou

psrepo

rted

improved

attitud

eto

asthma(F=11.94,p=

0.001),w

ithgreaterim

provem

entin

Iat

6mo(M

D4.11,95%

CI0.65–7.56,

p=0.02).

Rikkers-Mutsaerts2012

[57]

n=90

UNCLEARriskof

bias

Internet-based

self–

managem

entvs.usual

care.

FU:12mo

Target:A

dolescen

ts.

Com

pone

nts:Internet-

based

RCT.

Internet-based

self-

mon

itorin

gwith

algo

rithm

-based

advice.

Prog

rammeinclud

eded

ucation(web

-based

+grou

p),self-m

onito

ring

(FEV

1+ACQ),PA

APand

3–6moreview

.

12–18ywith

mild

tosevere

persistent

asthma

onregu

larICSmed

ication

andpo

orlycontrolledat

recruitm

ent.

Nobe

tween-grou

pdifferences

inexacerbatio

ns,p

hysicians’visitsor

teleph

onecontacts.

[1o]QoL

was

better

inIg

roup

at3

mo(PAQLQ

I:6.00

vs.C

:5.68;MD0.40,

95%

CI0.17–0.62)bu

tno

tat

12mo(I:

5.93

vs.C

:6.05;MD0.05,95%

CI0.50–

0.41).

Asthm

acontrolw

asim

proved

inI

grou

pat

3mo(ACQI:0.96

vs.C

:1.19;

MD−0.32,95%

CI−

0.56

to−0.08)bu

t

Pinnock et al. BMC Medicine (2017) 15:64 Page 13 of 32

Table

4Summarytableof

finding

sof

update

rand

omised

controlledtrialsandtheirrelevanceto

themeta-review

questio

ns(Con

tinued)

notat

12mo(I:0.83

vs.C

:0.79;MD

−0.05,95%

CI−

0.35

to0.25).

Shah

2011

[58]

150GPs

and201children

LOW

riskof

bias

GPtraining

(PACE

stud

y)vs.n

otraining

.FU

:12mo

Targets:Children

Com

pone

nts:GPtraining

Cluster

RCT.

GPs

participated

in2×3-h

worksho

pson

commun

icationand

educationstrategies

tofacilitatequ

ality

asthma

care.

150GPs

and221children

with

asthmain

theircare.

Nobe

tween-grou

pdifferencein

hospitalisation/A&E

visits(I:18%

vs.

C:12%

;differen

ce6%

,95%

CI−

4to

15).

Nobe

tween-grou

pdifferences

inscho

olabsenceor

parent

absenteeism

forchild’sasthma.

[1o]Morepatientsin

Igroup

GPs

had

aPA

AP(I:61%

vs.C

:46%

;differen

ce15%,95%

CI2–28).

vanGaalen2013

[59]

n=107

HIGHriskof

bias

Internet-based

self–

managem

entvs.

control(FU

ofSM

ASH

INGtrial).

FU:30mo

Target:A

dults

Com

pone

nts:Internet-

based

RCT(FUstud

y).

Education+PA

AP,

self-mon

itorin

gand

regu

larreview

.The200patientsin

original12-m

otrialw

ere

invitedforFU

after18

mo.

Adu

ltswith

asthmaaged

18–50y,usingICS.

107/200(54%

)participated

:Igrou

p:47/

101(47%

);Cgrou

p:60/99

(61%

).ParticipantsACQwas

similar,bu

tAQLQ

was

greaterthan

inno

n-participants.

At30

moafterbaseline,therewas

aslightlyattenu

ated

improvem

entfor

both

QoL

(AQLQ

adjusted

betw

een-

grou

pMD0.29,95%

CI0.01–0.57)and

ACQ(adjustedMDof

−0.33,95%

CI

−0.61

to−0.05)scores

infavour

ofthe

interven

tion.

Nobe

tween-grou

pdifferences

inFEV 1.

Won

g2012

[60]

n=80

HIGHriskof

bias

Symptom

-based

writtenPA

APvs.verbal

coun

selling

.FU

:6mo

Target:C

hildren,

ethn

icgrou

psCom

pone

nts:Written

PAAP

Sing

leblinde

dRC

T.Interven

tionwas

symptom

-based

PAAP

givenou

tat

initialcontact.

Outcomes

measuredat

baseline,3,6and9mo.

Malaysian

children(m

ixof

Malay,C

hine

seandIndian)

with

allseverities

ofasthma.Age

d6–17

y.Recruitm

entprocessno

tde

scrib

ed.

At6motherewas

nodifferencein

A&E

visits/unsched

uled

care

[interven

tion4(SD10.8)vs.con

trol

6(SD21.1);p=0.35].

At6motherewas

nodifferencein

prop

ortio

ncontrolled(ACT≥20

I:81%

vs.C

:87%

;p=0.50),with

noexacerbatio

ns(ACT≥20

I:89%

vs.C

:82%;p

=0.62)or

inQoL

[mean

PAQLQ

I:6.11

(SD0.88)vs.6.11

(SD1.09);

p=0.99].

Abb

reviations:A

&Eaccide

ntan

dem

erge

ncy,ACQ

Asthm

aCon

trol

Que

stionn

aire,A

CTAsthm

aCon

trol

Test,A

QLQ

Asthm

a-relatedQua

lityof

Life

Que

stionn

aire,C

control,CI

confiden

ceinterval,FEV

1forced

expiratory

volumein

onesecond

,FUfollow-up,

GPge

neralp

ractition

er,I

interven

tion,

ICSinha

ledcorticosteroid,m

AQLQ

miniA

sthm

a-relatedQua

lityof

Life

Que

stionn

aire,M

Dmeandiffer-

ence,m

omon

ths,PA

APpe

rson

alised

asthmaactio

nplan

,PAQLQ

paed

iatricasthma-relatedqu

ality

oflife,QoL

quality

oflife,

RCTrand

omised

controlledtrial,RR

riskratio

,SDstan

dard

deviation,

yyears

Pinnock et al. BMC Medicine (2017) 15:64 Page 14 of 32

ResultsDescription of the studies in the meta-reviewFigure 1 illustrates the PRISMA flow chart for bothreviews. After removal of duplicates, 9633 referenceswere identified from the initial PRISMS search and anadditional 6321 from the update search. From these, 25systematic reviews [23–47] were included in the PRISMSmeta-review, representing data from 240 unique RCTs.The year of review publication ranged from 1995 to2013, and included RCTs dated from 1979 to 2013.In addition we included 13 RCTs published since thelast search dates of the included reviews (2010 forchildren, 2012 for adults and 2011 for ethnic groups;see Additional file 2 for details) [48–60]. (For claritywe refer to these as “update RCTs”.) A further twosystematic reviews (which included a further fourRCTs) [61, 62] and six RCTs [63–68] were added afterthe pre-publication update. The RECURSIVE study in-cluded 24 RCTs with publication dates from 1993 to2015 [49, 69–91].

After excluding overlap, this represents 270 unique tri-als undertaken in at least 29 high- or middle-incomecountries: Argentina, Australia, Belgium, Brazil, Canada,Chile, Denmark, Finland, France, Germany, India,Israel, Italy, Jordan, Malaysia, Malta, Netherlands, NewZealand, Norway, Russia, Spain, Sweden, Switzerland,Taiwan, Trinidad, Turkey, UK, USA and Venezuela.In the 18 systematic reviews that reported the duration

of follow-up in their included RCTs [23–25, 27–29, 33,35, 38–40, 42–47, 61], the modal duration (in 10 of thereviews) was 12 months, with only 3% of reported RCTsfalling outside the range of 3–24 months. The updateRCTs had a similar profile, with 6 of 13 update RCTshaving a duration of 12 months (range 3–30 months).

Study quality and weight of evidenceTaking into consideration both study quality and totalpopulation size, 10 PRISMS reviews received anevidence weighting of three stars [27, 31, 32, 36–38, 40,41, 43, 46], 13 were weighted two star [23–26, 29, 30,

Fig. 1 PRISMA flowchart. Note: The initial RECURSIVE search included all long-term conditions: papers reporting asthma randomised controlledtrials (RCTs) were identified from 184 studies included in the full RECURSIVE report [14]

Pinnock et al. BMC Medicine (2017) 15:64 Page 15 of 32

33–35, 39, 42, 44, 45] and two were weighted one star[28, 47]. Of the PRISMS update RCTs, four were judgedto be at low risk of bias [50–52, 58], five at high risk ofbias [48, 49, 55, 59, 60] and in four the risk of bias wasunclear [53, 54, 56, 57]. Allocation concealment wasjudged as adequate in six of the 24 asthma studiesincluded in the RECURSIVE review [74, 76, 80, 83–85].Study quality is indicated in the first columns of Tables 3,4 and 5, with details of the quality assessments inAdditional file 4.

Overview of presentation of resultsTables 3, 4, 5 and 6 provide summaries of the studiesincluded in the PRISMS meta-review, update RCTs, theRECURSIVE review and pre-publication update withmore detailed tables in Additional file 5.

Can supported self-management reduce the use ofhealthcare resources and improve asthma control?Use of healthcare resourcesFigure 2 is a meta-Forest plot illustrating the meta-analyses (including three PRISMS 3* reviews and RECUR-SIVE) that report relative risks of admissions, A&E atten-dances and/or unscheduled consultations [27, 31, 38].Treatment event rates from the meta-analyses are inTable 7. These results suggest similar effects in adults[38], children [27] and mixed populations [31].Hospitalisations were reported in 12 reviews [25–29,

31, 35, 38, 40, 41, 44, 46]. Six meta-analyses (four 3*,two 2*) showed that self-management support interven-tions led to fewer hospital admissions [25–27, 31, 38, 41].Six narrative reviews of variable quality, reporting hetero-geneous interventions, showed inconsistent effects onhospitalisations [28, 29, 35, 40, 44, 46].Ten reviews reported A&E attendances [25–27, 29, 31,

35, 38, 40, 44, 46]. Four meta-analyses (three 3* [27, 31,38], one 2* [26]) reported a reduction in A&E atten-dances in the self-management intervention comparedto control groups. Four narrative reviews (one 3* [46],three 2* [25, 35, 44]) showed a reduction in A&E atten-dances in at least half of their included RCTs; one 3*review showed inconsistent results [40], and one 2*review showed no benefit on A&E attendances [29].Of the eight reviews that reported unscheduled care

[24, 27, 28, 31, 34, 35, 43, 44], three 3* meta-analysesreported fewer unscheduled consultations in participantswho received a self-management intervention whencompared to control [27, 31, 43]. Furthermore, three 2*narrative reviews reported that self-managementreduced unscheduled care in at least half their includedtrials [34, 35, 44]. The remaining two small or poorquality reviews had inconsistent results [24, 28].

Asthma controlOf the 10 reviews that reported measures of control[24, 28, 30, 31, 34, 35, 38, 41, 44, 46], three meta-analyses (two 3* [31, 41], one 2* [24]) and three narrativereviews [28, 35, 44] reported a reduction in symptoms inparticipants who received self-management interventionscompared to control groups. The other four narrativereviews (two 3* [30, 34], two 2* [38, 46]) had inconsistentresults [30, 34, 38] or showed no benefit on symptomcontrol [46]. The broader concept of quality of life wasreported as improved in some reviews [25, 30, 34, 46], butnot others [27, 29, 40, 44].Six reviews reported a reduction in days missed

from school or work [24, 29–31, 38, 41]. Two 3*meta-analyses [31, 41], two small reviews each withonly one RCT [24, 29] and five of the 13 RCTs in a2* narrative synthesis of school-based interventions[30] concluded that self-management interventionsreduced absenteeism. A single RCT reported in a 3*narrative review in adults concluded that asthmaeducation following A&E attendance had no effect onabsenteeism [38].

In which target groups has supported self-managementbeen shown to work?The systematic reviews encompassed a broad range ofpopulations in diverse healthcare and demographic set-tings with consistently positive findings. For example,the reviews included all ages [28, 31] or only children[24, 26, 27, 29, 30, 35, 40, 41] or adults [34, 38, 43, 46].Some focused on lower socioeconomic groups [35, 40]or ethnic minority communities [25, 29, 35]. The reviewsand RCTs identified in the PRISMS update typically builton this extensive generic evidence base and investigatedinterventions targeting specific groups such as urban[52, 54], rural [53], deprived communities [46, 52, 54],cultural groups [46, 54, 55, 60], adolescents [48, 54, 56,57] or older adults [49, 51]. Table 8 summarises the keystrategies used in trials to tailor interventions, or theirmode of delivery, to different groups.

Cultural groupsFour reviews explored the impact of self-management incultural groups [25, 29, 35, 46]. A 2* meta-analysisreported that culture-specific programmes reducedhospitalisations in children and improved quality of life inadults compared to generic interventions [25]. A 3* narra-tive synthesis found only two RCTs testing culturally tai-lored interventions, one of which improved quality of life[46]. The involvement of community health workers re-duced use of healthcare resources in two thirds, and im-proved symptoms in all seven RCTs included in a 2*narrative review [35]. An inpatient visit from a lay educa-tor to Black or Latino children improved self-efficacy and

Pinnock et al. BMC Medicine (2017) 15:64 Page 16 of 32

Table

5Summarytableof

stud

iesinclud

edin

theRECURSIVEhe

alth

econ

omicanalysis

Reference;Cou

ntry;

Allocatio

nconcealm

ent

Stud

ytype

;Participants,n;

Interven

tion(s)

Com

parison

Target

grou

p(s)

Health

econ

omicresults

Form

alhe

alth

econ

omic

evaluatio

n,cost-effectiven

ess

(societaland

health

service

perspe

ctive)

Qualityof

life/

asthmacontrol

Health

care

utilisatio

n(hospitalisation)

Totalh

ealth

care

costs

Unsched

uled

care

Baptist2013

[49]

US

Con

cealmen

tno

tadeq

uate

RCT

n=70

Person

alised

6-session

self-regu

latio

ned

ucation.

Usualcare.

FU:12mo

Older

adultswith

asthma(>65

y).

Meanage74

y.14%

male.

Prop

ortio

nwith

ACQ<0.75

was

greaterin

Igroup

than

Cgrou

p[I:

13(41.9%

)vs.C

:5(15.6%

)].

Igroup

hadfewer

hospitalisations

(I:0

vs.C

:4;p

=0.04).

n/a

Nodifferencein

A&E

visits(I:1vs.

C:2;p

=0.58).I

grou

phadfewer

unsche

duledvisits

(I:6vs.C

:14;

p=0.048).

n/a

Castro2003

[69]

US

Con

cealmen

tno

tadeq

uate

RCT

n=96

Education,

psycho

socialsupp

ort,

PAAPandco-

ordinatio

nof

care.

Usual(private)

prim

arycare.

FU:12mo

Inpatients,adults

with

asthma.

Meanage38

y.15%

male.

Nobe

tween-

grou

pdifference

inmeanAQLQ

[I:4.0(SD1.3)

vs.C

:3.9(SD1.5);

p=0.55].

Igroup

hadfewer

re-adm

ission

s/patient

[I:0.4(SD0.9)

vs.C

:0.9(SD1.5);p

=0.04].

Igroup

hadlower

costs/patient

[I:$5726(SD5679)

vs.C

:$12,188

(SD19,352);MD

$6,462;p

=0.03].

Nobe

tween-

grou

pdifferences

innu

mbe

rA&E

visits/patient

[I:1.9

(SD4.3)

vs.C

:1.4

(SD=1.5);

p=0.52].

n/a

Clark

2007

[70]

US

Con

cealmen

tno

tadeq

uate

RCT

n=808

Self-regu

latio

ninterven

tion;nu

rse

teleph

one-de

livered

.

Usualcare.

FU:12mo

Adu

ltwom

enwith

asthma.

Meanage49

y.100%

female

Nobe

tween-

grou

pdifference

inmeanAQLQ

[I:2.1(SD0.9)

vs.C

:2.1(SD0.9].

Nobe

tween-grou

pdifferencein

admission

s/patient

[I:0.2(SD0.7)

vs.C

:0.1

(SD0.5)]

n/a

Igroup

had

greaterredu

ction

inun

sche

duled

visits[m

ean

change

:I:−

0.63

(SD2.4)

vs.C

:−0.24

(SD1.5)].

n/a

deOliveira

1999

[71]

Brazil

Con

cealmen

tno

tadeq

uate

RCT

n=52

Outpatient

education

prog

ramme,includ

ing

awrittenPA

AP.

Usualcare.

FU:6

mo

Adu

lts;m

oderateto

severe

asthma.

Meanage38

y.15%

male.

Nobe

tween-

grou

pdifferences

inQoL

score[I:28

(SD17)

vs.C

:50(SD15);

p=0.0005].

Nobe

tween-grou

pdifferences

inadmission

s/patient

[I:0vs.C

:0.5(SD0.8);

p=0.08].

n/a

Igroup

hadfewer

A&E

visits/patient

[I:0.7(SD1.0)

vs.

C:2

(SD2)].

n/a

Gallefoss

2001

[72]

Norway

Con

cealmen

tno

tadeq

uate

RCT

n=78

Group

-plusindividu

alself-managem

ent

educationwith

awrit-

tenPA

AP.

Usualprim

ary

care.

FU:12mo

Adu

ltswith

asthma.

Meanage44

y.21%

male.

Better

QoL

(SGRQ

)in

Igroup

at12

mo[I:20

(SD15)

vs.C

:36.5(SD18);

MD16.3,95%

CI

16.3–24.4]

n/a

Nobe

tween-

grou

pdifferences

intotalcosts(in

NOK)

[I:10,500

(SD20,500)v

s.C:

16,000

(SD35,400);

p=0.510].

n/a

Increm

entalSGRQ

gain

16.3;health

costsdifference

NOK1900;allcost

diffNOK−5500.

Gruffydd

-Jon

es2005

[73]

UK

Con

cealmen

tno

tadeq

uate

RCT

n=174

Targeted

nurse-led

teleph

onereview

s,in-

clud

ingPA

APs.

Usualprim

ary

care.

FU:12mo

Adu

ltswith

asthma.

Meanage50

y.40%

male.

Nobe

tween-

grou

pdifference

inmeanchange

inACQ[I:−0.11

(95%

CI−

032to

0.11)vs.C

:−0.18

(95%

CI−

0.38

to0.02);p=0.349].

n/a

Nobe

tween-

grou

pdifference

intotalcosts[I:

£209.85(SD

220.94)vs.C:

£333.85(SD

410.64);MD

£122.35;p=0.071].

n/a

n/a

Pinnock et al. BMC Medicine (2017) 15:64 Page 17 of 32

Table

5Summarytableof

stud

iesinclud

edin

theRECURSIVEhe

alth

econ

omicanalysis(Con

tinued)

Hon

koop

2015

[74]

Nethe

rland

sAde

quate

concealm

ent

RCT

n=611

Nurse-ledcare

tosymptom

control(I)

(orFeNOcontrolled).

Usualcare

(partially

controlled).

FU:12mo

Adu

ltswith

asthma.

Meanage40

y.28%

male.

Nobe

tween-

grou

pdifference

inEQ

5D(QALYs)

(I:0.91

vs.C

:0.89;

MD0.01,95%

CI

−0.02

to0.04).

n/a

Nobe

tween-

grou

pdifference

intotalcosts[I:

$4591vs.C

:$4180;MD$411,

95%

CI−

904to

1797;p

>0.05].

n/a

n/a

Kaup

pine

n1998

[75]

Finland

Con

cealmen

tno

tadeq

uate

RCT

n=162

Intensiveed

ucation

(use

ofinhaleddrug

s,PEF,mon

itorin

gand

PAAP).

Con

ventional

education.

FU:12mo

Adu

lts,new

lydiagno

sedasthma.

Meanage43

y.44%

male.

Nobe

tween-

grou

pdifference

in15D[I:0.93

(95%

CI0.90–0.94)

vs.C

:0.91(95%

CI

0.89

to0.94);p=

0.47].

n/a

Igroup

had

greatertotalcosts

than

control[I:

£345

(95%

CI247–

1758)v

s.C:£294

(95%

CI0–8078);

p<0.001].

n/a

Intensive

education:

increm

entalg

ain

of0.02

15D.

Increm

ental

differencein

health

costsof

£51.

Kriege

r2015

[76]

US

Ade

quate

concealm

ent

RCT

n=366

Com

mun

ityhe

alth

worker-supp

orted

self-managem

ent.

Usualcare.

FU:12mo

Adu

ltswith

asthma.

Meanage41

y.27%

male.

Interven

tion

improved

QoL.

Meanchange

inmAQLQ

(I:0.95

vs.

C:0.36;MD0.50,

95%

CI0.28–0.71;

p<0.001).

Nodifferencein

meanchange

innu

mbe

rof

urge

ntcare

episod

es.(I:

−1.50

vs.C

:−1.60;

difference0.09,95%

CI−

0.59

to0.73;

p=0.78.)

n/a

n/a

n/a

Lahd

ensuo1996

[77]

Finland

Con

cealmen

tno

tadeq

uate

RCT

n=122

Self-managem

ent,

includ

ingbreathing

exercises,ed

ucation

andPEFmon

itorin

g.

Tradition

altreatm

ent.

FU:12m

Adu

ltswith

asthma.

Meanage43

y.48%

male.

Interven

tion

improved

QoL

SGRQ

(sym

ptom

domain)

[I:16.6

(SD15.9)vs.C

:8.4

(SD18.4);p=

0.009].

n/a

n/a

Igroup

hadfewer

unsche

duledcare

visits/patient/year

(I:0.5vs.C

:1;

p=0.04).

n/a

Levy

2000

[78]

UK

Con

cealmen

tno

tadeq

uate

RCT

n=211

Structured

education

with

PAAPby

A&E

specialistnu

rses.

Usualprim

ary

care.

FU:6

mo

Adu

ltswith

asthma.

Meanage40

yrs.

43%

male.

Nobe

tween-

grou

pdifference

inSG

RQ(I:30.25

vs.C

:28.73;M

D1.52,95%

CI−

4.05

to7.09).

Nobe

tween-grou

pdifferencein

hospital

consultatio

ns[m

edian

(IQR)

I:0(1–3)v

s.C:0

(1–6);p=0.17].

n/a

Nobe

tween-

grou

pdifference

inGPconsulta-

tions

[med

ian

(IQR)

I:0(1–7)vs.

C:0

(1–7);

p=0.14].

n/a

Mancuso

2011

[79]

US

Con

cealmen

tno

tadeq

uate

RCT

n=296

Self-managem

ent

workboo

k,be

haviou

ralcon

tract,

teleph

onecalls.

Inform

ation/PEF

training

.FU

:12mo

Adu

ltsattend

ingA&E

with

asthma.

Meanage43

y.23%

male.

Nobe

tween-

grou

pdifference

inchange

inAQLQ

at1y(I:

0.04

vs.C

:0.18;

MD0.22,95%

CI

−0.15

to0.60).

n/a

n/a

Nobe

tween-

grou

pdifference

inprop

ortio

nwith

A&E

visits(I:13%

vs.C

:11%

).

n/a

McLean2003

[80]

Canada

Ade

quate

concealm

ent

RCT

n=225

Usualph

armacist

care.

FU:7

mo

Adu

ltswith

asthma.

Meanage38

y.47%

male.

Interven

tion

improved

QoL

asmeanAQLQ

(I:

Nobe

tween-grou

pdifferencein

hospitali-

satio

ns(I:0.078vs.C

:0.16;p

=0.94).

Interven

tion

redu

cedtotal

costs(costspe

r

Nobe

tween-

grou

pdifference

inA&E

visits

n/a

Pinnock et al. BMC Medicine (2017) 15:64 Page 18 of 32

Table

5Summarytableof

stud

iesinclud

edin

theRECURSIVEhe

alth

econ

omicanalysis(Con

tinued)

Pharmacist-ledself-

managem

ent,with

PAAP.

5.13

vs.C

:4.40;p

=0.0001).

patient

I:$150

vs.

C:$351).

(I:0.04

vs.C

:0.21;

p=0.48).

Mou

dgil2000

[81]

UK

Con

cealmen

tno

tadeq

uate

RCT

n=689

Individu

aled

ucation

andop

timisationof

drug

therapy.

Usualprim

ary

care.

FU:12mo

Adu

ltswith

asthma.

Meanage35

y.47%

male.

Greater

improvem

entin

QoL

inIg

roup

(MDin

change

inAQLQ

0.22

,95%

CI0.15–0.29).

Nobe

tween-grou

pdifferencein

hospitali-

satio

ns(OR0.51,95%

CI0.22–1.14).

n/a

Nobe

tween-

grou

pdifference

inA&E

visits(OR

0.63,95%

CI0.23–

1.68).

n/a

Pilotto2004

[82]

Australia

Con

cealmen

tno

tadeq

uate

Cluster

RCT

n=170

Nurse-run

asthma

clinicsinclud

ing

provisionof

PAAPs.

Usualprim

ary

care.

FU:9

mo

Adu

ltswith

asthma.

Meanage50

y.48%

male.

Nobe

tween-

grou

pdifference

inSG

RQ(I:27.3vs.

C:27.0;MD−0.5

(−4.0to

2.9).

Nobe

tween-grou

pdifferencein

numbe

radmitted

(I:2vs.C

:0;

p=0.499).

n/a

Nobe

tween-

grou

pdifference

innu

mbe

rattend

-ingA&E

(I:2vs.C

:0;p=0.499).

n/a

Pinn

ock2003

[83]

UK

Ade

quate

concealm

ent

RCT

n=278

Nurse-delivered

,routineteleph

one

review

.

Usualprim

ary

care.

FU:3

mo

Adu

ltswith

asthma.

Meanage57

y.41%

male.

Nobe

tween-

grou

pdifference

inmAQLQ

(I:5.17

vs.C

:5.17;MD

0.22,95%

CI−

0.15

to0.60).

Nopatientsin

either

grou

phadaho

spital

admission

forasthma.

n/a

Nopatientsin

either

grou

phad

anA&E

attend

ance

for

asthma

n/a

Price2004

[84]

UK

Ade

quate

concealm

ent

Cluster

RCT

n=1553

Use

ofPA

APs

with

adjustable

mainten

ance

dosing

.

Usualcare.

FU:3

mo

Adu

ltswith

asthma.

Meanage48

y.41%

male.

Nobe

tween-

grou

pdifference

inprop

ortio

nwith

improved

QoL

(I:22.5%

vs.C

:23.6%).

Nobe

tween-grou

pdifferencein

hospital

admission

s(I:2vs.C

:2).

Interven

tion

redu

cedtotal

costs(cost/day/

patient

I:£1.13vs.

C:£1.31;M

D−

£0.17,95%

CI

-£0.11

to-£0.23).

Nobe

tween-

grou

pdifference

inA&E

visits(I:5

vs.C

:11).

n/a

Ryan

2012

[85]

UK

Ade

quate

concealm

ent

RCT

n=288

Mob

ileph

one

supp

ortedself-

managem

ent.

Pape

r-based

PAAPs.

FU:6

mo

Adu

ltswith

asthma.

Meanage52

y.41%

male.

Nobe

tween-

grou

pdifference

inmeanchange

inmAQLQ

(differen

ce−0.10,

95%

CI−

0.16

to0.34).

Nobe

tween-grou

pdifferencein

hospital

admission

sforasthma

(I:3vs.C

:1).

n/a

Nobe

tween-

grou

pdifference

inA&E

atten-

dances

forasthma

(I:3vs.C

:0).

n/a

Sche

rmer

2002

[86]

Nethe

rland

sCon

cealmen

tno

tadeq

uate

RCT

n=193

Guide

dself-

managem

entwith

educationandPEF

mon

itorin

g.

Usualprim

ary

care.

FU:24mo

Adu

ltswith

asthma.

Meanage39

y.42%

male.

Nobe

tween-

grou

pdifference

intotalA

QLQ

(I:39

vs.C

:29;MD

10,95%

CI−

3to

23).

Noho

spital

admission

sin

either

treatm

entgrou

p.

Nobe

tween-

grou

pdifference

intotalcosts(I:

€1084vs.C

:€1097;MD−€13).

NoA&E

visitsin

either

treatm

ent

grou

p.

Increm

entalQ

ALY

gain

0.015.

Increm

entaltotal

cost−€13.

Increm

ental

health

cost€11.

Increm

ental

health

ICER

€33/

QALY.

Shelledy

2009

[87]

US

Con

cealmen

tno

tadeq

uate

RCT

n=166

Nurse-(N)vs.

respiratory

therapist-

Usualprim

ary

care.

FU:6

mo

Adu

lts:A

&Eor

admitted

with

asthma.

Meanage44

y.22%

male.

RTIg

roup

had

greaterchange

inSG

RQ[I(RT)−11.0

vs.I(N)−6.0vs.C

:−2.5,p<0.05).

Igroup

hadfewer

hospitalisations

[I(RT):

0.04

vs.I(N):0vs.C

:0.20;p

<0.05).

Igroup

hadlower

hospitalisation

costs[I(RT):$202

vs.I(N):$0

vs.C

:$1065;p<0.05].

Nobe

tween-

grou

pdifference

inA&E

visits[I(RT):

0.09

vs.I(N):0.26

vs.C

:0.37)].

n/a

Pinnock et al. BMC Medicine (2017) 15:64 Page 19 of 32

Table

5Summarytableof

stud

iesinclud

edin

theRECURSIVEhe

alth

econ

omicanalysis(Con

tinued)

(RT)

leded

ucation

andmanagem

ent.

Sund

berg

2005

[88]

Swed

enCon

cealmen

tno

tadeq

uate

RCT

n=97

Interactivecompu

ter-

baseded

ucationplus

nursesupp

ort.

Usualcare.

FU:12mo

Youn

gadultswith

asthma.Meanage19

y. 55%

male.

Nobe

tween-

grou

pdifference

inLiving

with

Asthm

aQuestion-

naire

(I:163.6vs.

C:166.2,p

>0.05).

Nobe

tween-grou

pdifferencein

hospital

admission

s(1

admis-

sion

ineach

grou

p).

n/a

Nobe

tween-

grou

pdifference

inA&E

visits(I:17

vs.C

:16).

n/a

vande

rMeer2011

[89]

Nethe

rland

sCon

cealmen

tno

tadeq

uate

RCT

n=200

Internet-based

self-

managem

ent

prog

ramme,includ

ing

electron

icPA

AP.

Usualou

tpatient

care.

FU:12mo

Adu

ltswith

asthma.

Meanage37

y.55%

male.

Nobe

tween-

grou

pdifference

inEQ

5D(I:0.93

vs.

C:0.89;difference

0.006,95%

CI

−0.042to

0.054).

Nobe

tween-grou

pdifferencein

hospital

admission

s(m

ean

cost:I:$571vs.C

:$589;M

D−17;

p=0.95).

Nobe

tween-

grou

pdifference

intotalh

ealth

care

costs(I:$2555vs.

C:$2518;M

D−$37;p=0.94).

n/a

Increm

entalQ

ALY

gain

0.024.

Increm

entaltotal

cost$641.

Increm

ental

health

cost$37.

Increm

ental

health

ICER

$1541/QALY.

Yilm

az2002

[90]

Turkey

Con

cealmen

tno

tadeq

uate

RCT

n=80

Outpatient

clinic,

specialedu

catio

nprog

ramme.

Usualprim

ary

care.

FU:36mo

Adu

ltswith

asthma.

Meanage29

y.37%

male.

Igroup

had

greater

improvem

entsin

AQLQ

(I:197.1vs.

C:176.7;

p=0.009).

Nobe

tween-grou

pdifferencein

hospitali-

satio

ns(I:0vs.C

:4);p

>0.05.

n/a

Igroup

hadfewer

A&E

visits(I:0vs.

C:7;p

=0.01).

n/a

Yoon

1993

[91]

Australia

Con

cealmen

tno

tadeq

uate

RCT

n=76

Brief,grou

p-based,

educationwith

aPA

AP.

Usualou

tpatient

care.

FU:10mo

Inpatient

adults.

Meanageno

trepo

rted

.28%

male.

Nobe

tween-

grou

pdifference

inQoL

[I:4.0(SD

4.38)vs.C

:3.96

(SD=3.34);

p>0.05).

Igroup

hadfewer

participantswith

hospitaladm

ission

s(I:1vs.C

:7;p

<0.001).

n/a

Nobe

tween-

grou

pdifference

inA&E

visits(I:3

vs.C

:7).

n/a

Abb

reviations:A

&Eaccide

ntan

dem

erge

ncy,ACQ

Asthm

aCon

trol

Que

stionn

aire,A

QLQ

Asthm

aQua

lityOfLife

Que

stionn

aire,C

control,CI

confiden

ceinterval,EQ5D

EuroQol

Five

Dim

ension

sQue

stionn

aire,FeN

Ofractio

nale

xhaled

nitricoxide,

FUfollow-up,

GPge

neralp

ractition

er,I

interven

tion,

ICER

increm

entalcost-effectiven

essratio

,IQRinterqua

rtile

rang

e,mAQALminiA

sthm

aQua

lityOfLife

Que

stionn

aire,M

Dmean

differen

ce,m

omon

th,N

nurse,

n/ano

tavailable,

PAAPpe

rson

alised

asthmaactio

nplan

,PEF

peak

expiratory

flow,Q

ALY

quality

-adjustedlifeyears,QoL

quality

oflife,

RCTrand

omised

controlledtrial,RT

respira

tory

therap

ist,SD

stan

dard

deviation,

SGRQ

StGeo

rge’sRe

spira

tory

Que

stionn

aire,y

year

Pinnock et al. BMC Medicine (2017) 15:64 Page 20 of 32

Table

6Focuseddata

extractio

nfro

madditio

nalstudies

iden

tifiedby

forw

ardcitatio

npriorto

publication

Reference;RC

Ts,n;

Participants,n;D

ate

rang

eRC

Ts

Com

parison

Relevanceto

meta-review

questio

ns:

Interven

tions

includ

edTarget

grou

p(s)

Synthe

sis

Mainresults

Whatistheim

pact?

Target

grou

ps?

Which

compo

nents?

Con

text?

System

aticreview

s

Coe

lho2016

[61]

17RC

Ts;5879

participants

RCTs

2005–2013

Scho

ol-based

asthma

educationvs.usual

care.

FU:m

inim

um1mo

Target:Schoo

lchildren

Educationalinterventions

toindividu

als,grou

psor

classesby

healthcare

profession

als,teache

rs,

educatorsand/or

IT.

Scho

olchildrenwith

asthmaand/or

who

lescho

ol.

Narrativeanalysis

6/17

show

edaredu

ctionin

unsche

duledcare;5/17show

eda

redu

ctionof

theasthmasymptom

s;5/17

redu

cedscho

olabsenteeism;

7/17

improved

QoL

ofthe

individu

als;8/17

show

edthat

asthma

educationim

proved

know

ledg

e.

McLean2016

[62]

5RC

Ts595participants

RCTs

2011–2013

Interactivedigital

interven

tions

vs.usual

care.

FU:10weeks

to12

mo

Impact

Com

pone

nts:

Techno

logy-based

interven

tions

Interactiveinterven

tion

(i.e.en

terin

gdata,

receivingtailored

feed

back,m

aking

choices)accessed

throug

han

appthat

provides

self-

managem

entinform

ation.

Adu

lts(≥16

y)with

asthma.

Meta-analysis

Meta-analyses

(3stud

ies)show

edno

sign

ificant

differencein

asthma

control(SM

D0.21,95%

CI−

0.05

to0.42)or

asthmaQoL

(SMD0.05,95%

CI−

0.22

to0.32)bu

the

teroge

neity

was

very

high

.Removalof

theou

tlier

stud

yredu

ced

heteroge

neity

andindicated

sign

ificant

improvem

entforbo

thasthmacontrol(SM

D0.54,95%

CI

0.22–0.86)

andasthmaQoL

(SMD

0.45,95%

CI0.13–0.77).

Rand

omised

trials

Hoskins

2016

[63]

48participants

Goal-settin

g+SM

/PA

APs

vs.usualcare.

Com

pone

nts:Goal-settin

gPracticeasthmanu

rses

traine

din

goal-settin

gapproach.

Prim

arycare

patients

dueareview

.Cluster

feasibility

RCT.

FU:6

mo

Difficulty

recruitin

g:10/124

practices

participated

and48

patients.No

betw

een-grou

pdifferencein

QoL

[mAQLQ

I:6.20

(SD0.76,95%

CI

5.76–6.65)

vs.C

:6.1(SD0.81,95%

CI

5.63–6.57),M

D0.1].

Moraw

ska2016

[64]

107participants

Gen

ericparenting

skillsvs

usualcare.

Com

pone

nts:Parenting

skills

Parentingskillsfor

managingLTCs+asthma

‘take-hom

etip

ssheets’.

Parentsof

children

2–10

ywith

asthma

and/or

eczema.

RCT.FU

:6mo

Betw

een-grou

pim

provem

entin

parents’self-efficacyandchilds’

‘eczem

abe

haviou

r’,bu

tno

teq

uivalent

asthmaou

tcom

es.

Parent

andfamily

gene

ricQoL

improved

(p=0.01).

Plaza2015

[65]

230participants

Traine

dpractices

(I)vs.spe

cialistun

it(Is)

vs.usualcare

(C).

Impact:

Com

pone

nts:Education

prog

ramme

Basicinform

ationon

asthma,inhaler

techniqu

e;provisionof

aPA

AP.

Adu

ltswith

persistent

asthma.

Cluster

RCT.FU

:12

mo

Igroup

shadfewer

unsche

duled

visits[I:0.8(SD1.4)

andIs :0.3(SD

0.7)

vs.C

:1.3(SD1.7);p

=0.001],and

greaterim

provem

entsin

asthma

control(p=0.042)

andQoL

(p=0.019).

Pinnock et al. BMC Medicine (2017) 15:64 Page 21 of 32

Table

6Focuseddata

extractio

nfro

madditio

nalstudies

iden

tifiedby

forw

ardcitatio

npriorto

publication(Con

tinued)

Rice

2015

[66]

711participants

PAAP+inpatient

lay

educator

vs.PAAP.

Com

pone

nts:Inpatient

layed

ucator

EncourageFU

attend

ance,b

uild

self-

efficacy,setgo

als,

overcomebarriers.

Children2–17

yadmitted

with

asthma.

RCT.

FU:1

mo

Nodifferencein

attend

ance

atFU

appo

intm

ent.Ig

roup

hadgreater

preven

teruse(OR2.4,95%

CI

1.3–4.2),PAAPow

nership(OR2.0,

95%

CI1.3–3.0)a

ndim

proved

self-efficacy(p=0.04).

Yeh2016

[67]

76participants

Family

prog

ramme

(+PA

AP)

vs.usualcare

(+PA

AP).

Com

pone

nts:Family

empo

wermen

tFamily

empo

wermen

tto

redu

ceparentalstress,

increase

family

functio

ning

.

Children6–12

ywith

asthma.

RCT.

FU:3

mo

Ifam

ilies

hadredu

cedparentalstress

inde

x(p=0.026)

andim

proved

family

environm

entscores

(p<

0.0001),im

proved

lung

functio

n,less

disturbe

dsleep,

less

coug

hbu

tno

differencein

whe

eze.

Zairina

2016

[68]

72participants

Telehe

alth

supp

orted

PAAPvs.usualcare.

Com

pone

nts:Telehe

alth

Telehe

alth

(FEV

1,symptom

s)mon

itored

weekly.

Preg

nant

wom

enwith

mod

erate/severe

asthma

RCT.

FU:6

mo

Telehe

alth

improved

ACQ[M

D0.36

(SD0.15,95%

CI−

0.66

to−0.07)]and

mAQLQ

[MD0.72

(SD0.22;95%

CI

0.29–1.16)].

Nodifferencein

perin

atalou

tcom

es.

Abb

reviations:A

CQAsthm

aCon

trol

Que

stionn

aire,A

QLQ

Asthm

aQua

lityOfLife

Que

stionn

aire,C

control,CI

confiden

ceinterval,FEV

1forced

expiratory

volumein

onesecond

,FUfollow-up,

Iintervention,

LTClong

-term

cond

ition

,mAQALminiA

sthm

aQua

lityOfLife

Que

stionn

aire,M

Dmeandifferen

ce,m

omon

th,O

Rod

dsratio

,PAAPpe

rson

alised

asthmaactio

nplan

,QoL

quality

oflife,

RCTrand

omised

controlledtrial,SD

stan

dard

de-

viation,

SMDstan

dardised

meandifferen

ce,y

year

Pinnock et al. BMC Medicine (2017) 15:64 Page 22 of 32

action plan ownership 1 month post-discharge [66]. Incontrast, three generic interventions in US minority popu-lations showed no improvement [46]. Update RCTs, someunderpowered, in indigenous populations had inconsistentoutcomes [29, 48, 55, 60].

A&E attendeesTwo 3* meta-analyses demonstrated reduced use ofhealthcare resources (admissions, A&E attendancesand unscheduled consultations) in adults recruitedduring A&E attendance (13 RCTs) [38] and in

children with a history of A&E attendance in theprevious 12 months (38 RCTs) [27]. Neither reviewfound improved markers of asthma control [27, 38],though an update RCT in paediatric A&E attendees(low risk of bias) found that children dischargedwith an action plan had fewer symptoms at 28 dayscompared with usual care [50].

Specific age groupsSchool-based interventions [30], often using informa-tion technology-based programmes [30] or delivered

Table 7 Treatment event rates from the meta-analyses

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

Abbreviations: A&E accident and emergency

Fig. 2 Meta-Forest plot of healthcare resource use from meta-analyses. This meta-Forest plot displays the summary data from the PRISMS systematicreviews that reported relative risk (RR). Note that meta-analysis is inappropriate at meta-review level owing to the overlap of included randomisedcontrolled trials between reviews

Pinnock et al. BMC Medicine (2017) 15:64 Page 23 of 32

Table 8 Tailoring of self-management support for targeted populations

Group Key strategies Description of tailoring ofself-management intervention

Relevant systematic reviews/update RCTs

Evidence

Cultural groups Cultural tailoring Culturally orientated self-management programmes includingindividual sessions with language-appropriate asthma educators,videos/workbooks featuring culturallyappropriate role models, educationappropriate to socioeconomiccontext, strategies for use of localhealthcare services, asthma actionplans.

**Bailey 2009 [25]Adults and children fromminority groups

Culture-specific programmesare more effective thangeneric programmes inimproving QoL, knowledgeand asthma control but notall asthma outcomes.

Culturally tailored, community-basedinterventions in which healthcareproviders (pharmacists, asthmaeducator, social workers, respiratorynurses) provided language-appropriate education programmesincluding health literacy-focusedteaching, use of videos, asthmaphysiology and management, inhalertechnique, PAAP.

***Press 2012 [46]Adults from minority groupsin the USA

The 5 (of 15) educationstudies that were culturallytailored showed reduced useof unscheduled care andimproved QoL, but this is notcompared to non-tailoredinterventions.

Internet-based programmedeveloped to deliver education anda behaviour change intervention toAfrican-Americans adolescents.Strategies include voice-overs toaccommodate literacy limitationsand advice delivered by a ‘discjockey’.

(RCT) Joseph 2013 [54]Young teens

The intervention reducedsymptom-free days but hadno effect on A&E visits/hospitalisations.

Communityworkers

Community health worker from thesame/very similar community asparticipating families providedindividually tailored education athome visits. Topics included asthma,lifestyle and trigger avoidance, withresources to reduce allergenexposure and smoking cessationsupport.

**Postma 2009 [35]Ethnic minority children withasthma

Interventions involvingcommunity health workersreduced emergency andurgent care use in somebut not all studies.

Indigenous healthcare workersprovided personalised, child-friendly,culturally appropriate education ma-terials at home visits to reinforceclinical consultations.

**Chang 2010 [29]Ethnic minority children withasthma

The involvement ofindigenous healthcareworkers in asthmaprogrammes (1 RCT)improved control and QoLbut not unscheduled care.

A&E attendees Education duringthe A&Eattendance

Education sessions conducted byasthma or A&E nurses, or, less often,respiratory specialists or aphysiotherapist. Content varied,usually including triggers, PAAPsand/or inhaler technique.

***Tapp 2007 [38]Adult A&E attendees

Education delivered in A&Ereduced subsequent hospitaladmissions but not A&Eattendances. Effect on QoLwas inconsistent.

PAAP, completed by the A&Ephysician, coupled with theprescription provided on dischargefrom A&E.

(RCT) Ducharme 2011 [50]Children 1–17 y, A&Eattendees

Provision of a PAAP increasedpatient adherence to steroids(oral/inhaled), and improvedasthma control.

Education afterA&E

Education delivered by a healthcareprofessional or asthma educatorshortly after an A&E attendance,including triggers and PAAPs, to thechild and their carers.

***Boyd 2009 [27]Children, A&E attendees

Asthma education reducedA&E attendances andadmissions, but had no effecton QoL.

Schoolchildren School-basedprogrammes

School-based group education, themajority including education forclassmates without asthma.

**Coffman 2009 [30]Children

The intervention improvesknowledge, self-efficacy andself-management behaviours,but inconsistent effect onasthma control.

Pinnock et al. BMC Medicine (2017) 15:64 Page 24 of 32

by peers [48, 56], improved quality of life and, insome cases, reduced absenteeism [30, 48, 56, 61].Generic parenting skills initiatives improved self-efficacy in families struggling to manage young chil-dren with asthma, with inconsistent effect on asthmaoutcomes [64, 67].Two update RCTs reported interventions in older

people that improved control and quality of life [49,51], and one reduced use of unscheduled care [49]. A

key feature of both complex interventions was astructured approach to tailoring in order to meetpersonal goals or address individual problems.

Which components of supported self-management areimportant?A 3* meta-analysis (36 RCTs; 6090 participants of all agesrecruited from primary and secondary care settings)defined optimal self-management as education including

Table 8 Tailoring of self-management support for targeted populations (Continued)

16 short group educational sessions,including strategies for problemsolving, delivered in the schoollunch break.

Horner 2014 [53]Grades 2–5 (7–11 y)

Compared to generic healtheducation, the interventionimproved self-efficacy buthad no effect on admissions,A&E visits or QoL.

Peer-ledprogrammes

Year 11 pupils were trained todeliver the school-based asthmaeducational lessons to youngerpupils.

Al-Sheyab 2012 [48]Adolescents

Compared to children incontrol schools, knowledgeand QoL improved. Alsoincreased self-efficacy toresist smoking.

Asthma self-management skills andpsychosocial skills taught at a daycamp by peer leaders followed bymonthly peer telephone contact.

Rhee 2011 [56]Adolescents 13–17 y

The intervention group hadimproved QoL and positive‘attitude to illness’ comparedto those attending adult-ledcamps.

Technology-based Internet-based interventions,delivered at home, clinicor school, which delivereda psycho-educational programmeinvolving information andskills training modulestargeting improved healthoutcomes.

**Stinson 2009 [47]Children 4–17 y

The majority of studiesreported improvement insymptoms, but impact onother outcomes wasinconsistent.

Theoretically based asthmacomputer programmewith core modules (adherence,inhaler use, smoking reduction),with tailored sub-modulesto address specificbehavioural traits.

Joseph 2013 [54]9–12 grade (14–18 y)

The intervention improvedsymptom control, but had noeffect on A&E visits/hospitalisations.

Internet-based self-managementprogramme covering education,self-monitoring and an electronicaction plan, and encouraging regularmedical review. Supported by 2face-to-face groups.

Rikkers-Mutsaerts 2012 [57]Adolescents 12–18 y

QoL and asthma controlimproved compared to usualcare, but no difference in useof healthcare resources.

Elderly Goal-setting Six-session programme, conductedby a health educator in groups(n = 3) and telephone calls (n = 3).Participants selected anasthma-specific goal, identifiedproblems and addressedpotential barriers.

(RCT) Baptist 2013 [49]≥65 y

Compared to educationalone, the interventionimproved asthma control andQoL, but not unscheduledcare.

Addressingindividualconcerns

Specific concerns, identified with thePatient Assessment and ConcernsTool (PACT), were addressed in anhour-long session. Both groups hadstandard education (inhalertechnique, PAAP).

(RCT) Goeman 2013 [51]≥55 y

Compared to usual care,asthma control and QoL wasimproved by educationtailored to individual patientconcerns and unmet needs.

Abbreviations: A&E accident and emergency, PAAP personalised asthma action plan, QoL quality of life, RCT randomised controlled trial

Pinnock et al. BMC Medicine (2017) 15:64 Page 25 of 32

advice on self-monitoring and a written action planthat was supported by regular professional review[31]. There is evidence that reducing the intensity ofself-management education or level of clinical reviewmay reduce its effectiveness [36].

Components of an action planThe components of an action plan were further de-fined in two 3* and three 2* reviews [23, 24, 32, 36,39]. In adults, self-monitoring based on peak flow orsymptoms is equally effective [32, 36, 39]. In a com-parison in children, symptom-based plans were moreeffective at reducing unscheduled healthcare [23], andequally effective at improving most measures ofasthma control; the exception was days with symp-toms, which were reduced more by peak-flow-basedthan symptom-based plans [23]. A 3* review con-cluded that action plans with between two and fouraction points, including recommendations on increas-ing inhaled corticosteroids and initiating oral cortico-steroids, were consistently effective in reducingadmissions and A&E attendances [32].

Behavioural change techniquesOne 3* meta-analysis demonstrated that self-managementinterventions that incorporated specific behaviour changetechniques reduced unscheduled care and improved con-trol [43]. Meta-regression of the data from the 38 RCTs(7883 participants) concluded that active involvement ofparticipants in the intervention was a key factor in redu-cing unscheduled healthcare [43]. More specifically, iden-tifying individual behavioural traits (e.g. rebelliousness,low perceived emotional support) in adolescents en-abled targeted use of behavioural change techniques[54]. A goal-setting approach proved challenging toimplement in primary care settings [63].

TechnologyTwo 1* narrative reviews investigated computer- orinternet-based interactive self-management programmes[28, 47]. The effect on healthcare utilisation was incon-sistent, confirmed by a recent review identified in thepre-publication update [62], though both showedimprovement in symptoms [28] and/or quality of life[28, 47]. Two update RCTs of web-based self-management programmes for adolescents also showedimproved asthma control [54, 57], and an extendedfollow-up of RCT participants concluded that theseeffects could be sustained 18 months after conclusion ofthe trial [59]. Several school-based programmes usedtechnology-based interventions to improve control andreduce absenteeism [30]. Supported self-managementusing mobile phone technology currently has a limitedand inconclusive evidence base [42, 45], though a recent

RCT in pregnancy demonstrated improved asthma con-trol and quality of life [68].

Which contextual factors influence effectiveness?Resonating with the concept of ‘optimal’ self-management(education, an action plan and regular review) [31], a 3*meta-analysis identified that omitting regular review(1 RCT) or reducing intensity of education (1 RCT)was associated with a smaller reduction in unsched-uled consultations [36]. A 2* meta-analysis analysedthe findings of 18 RCTs (3006 participants) accordingto the components of the Chronic Care Model [92].Interventions that included all four components had agreater effect on adherence to inhaled corticosteroidscompared to trials including self-management unsup-ported by the organisational components [33].

Organisational role in promoting supported self-managementA 3* narrative review of 14 RCTs (4588 participants) con-cluded that proactive organisational systems can increaseaction plan ownership by promoting uptake of asthmareviews and implementing (and monitoring) structuredmanagement systems for asthma care [37]. A recent RCTof a structured approach to self-management education inboth primary care and specialist units improved asthmacontrol and reduced unscheduled care [65], and a largecluster RCT at low risk of bias showed an increased adher-ence to guidelines and reduced asthma symptoms bysystematically providing individualised prompts to generalpractitioners and parents of children with asthma [52].Automatically linking an action plan to prescriptions givento patients being discharged from A&E improved clinicianmanagement and patient uptake of steroid courses [50].

What is the effect of supported self-management onhealthcare utilisation and costs?The RECURSIVE meta-analysis confirmed that self-management support interventions for people withasthma are associated with significant improvements inquality-of-life outcomes (SMD 0.26, 95% CI 0.12–0.39),significant small decreases in hospitalisation rates andcosts (SMD −0.21, 95% CI −0.40 to −0.01), significantsmall decreases in A&E visits (SMD −0.25, 95% CI −0.49to −0.01), and non-significant small increases in totalhealthcare costs (SMD 0.13, 95% CI −0.09 to 0.34).Figure 3 shows a Forest plot of the total costs.

What is the evidence that supported self-management forasthma can reduce costs without compromising outcomes?Figure 4 shows the overall permutation plot of thestudies (n = 21) reporting data on both quality of life andhealthcare utilisation. The majority of the studies onquality of life versus costs related to hospitalisations andA&E attendances were in the right-down quadrant,

Pinnock et al. BMC Medicine (2017) 15:64 Page 26 of 32

indicating cost-effectiveness (reduced healthcare utilisa-tion and improved quality of life). However, in terms oftotal costs (n = 7), the picture was mixed with morestudies around zero and the right-up quadrant, indicat-ing that similar costs or small cost increases are neces-sary to achieve better quality of life.

What is the evidence that supported self-management forasthma is cost-effective?Four studies applied formal economic analyses; twoshowed that self-management support interventions weredominant (i.e. significantly better health outcomes withsignificantly lower costs) [72, 86], and two produced non-

Fig. 3 Meta-analysis of total costs. CI confidence interval, ES effect size

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 ofself-management interventions on outcomes (quality of life) and utilisation (hospitalisations and total costs) can be visualised simultaneously byplacing them in quadrants of the cost-effectiveness plane depending on the pattern of outcomes. Such plots identify studies in the appropriatequadrant (i.e. those that reduce costs without compromising outcomes) and those in problematic quadrants (i.e. those that reduce costs but alsocompromise outcomes, or those that compromise both outcomes and costs).

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significant ratios between costs and benefits at levels likelyto appeal to decision-makers (better outcomes with non-significant increases in costs) [75, 89] (see Additional file 5for more details).Thus, the benefits derived by supported self-management

interventions are associated with reductions in key areas ofhealthcare utilisation such as hospitalisations and A&Eattendances and can be delivered at similar levels of totalcosts to usual care.

DiscussionSummary of findingsExtensive evidence (n = 270 RCTs) derived from a broadrange of demographic and healthcare settings revealsthat supported self-management can reduce hospitalisa-tions, A&E attendances and unscheduled consultations,and improve markers of control and quality of life forpeople with asthma. Core components of effective self-management are education, provision of an action planand the support of regular professional review. Effective-ness has been demonstrated in diverse cultural, clinicaland demographic groups, with evidence that tailoredprogrammes have greater impact than generic interven-tions. A range of modes of delivery (including telehealth-care) may be employed to suit preferences and context.The cost of providing self-management support is offsetby a reduction in hospitalisations and unscheduledhealthcare.

Interpretation of findingsThe literature on asthma self-management is particularlywell developed and may thus be an exemplar for otherLTCs [13, 14]. The 16 systematic reviews reporting ef-fectiveness were typically large (five included data from>5000 participants [27, 30, 31, 41, 43]) and had consist-ently positive results, suggesting a mature evidence base,unlikely to be influenced by further trials. Outcomes insubgroups were more often the subject of the updateRCTs as the field moves on from demonstrating overalleffectiveness to investigating the impact in specifictarget groups [48–58, 60, 61, 72], demographic contexts[52–54, 66], or mode of delivery [54, 59, 62, 72].Self-management support for asthma is a complex

intervention and successful interventions were multi-component, including education, trigger avoidance,teaching self-monitoring, optimal treatment strategies,promotion of adherence and behaviour change tech-niques, many of which are common to self-managementin other LTCs [6]. Appropriately in a variable condition[4], the hallmark of asthma self-management is theprovision of an action plan with advice on recognisingand responding to deterioration in control [4, 32].People with asthma, however, have broader concerns asthey accommodate the condition within their lives and

the action plan needs to be embedded in support for‘living with asthma’ [93].Individuals with LTCs adjust medical regimes and self-

management strategies to fit into their own lives andhealth beliefs [13]. Meta-reviews, for example in type 2diabetes [94, 95], hypertension [96] and asthma [25],have emphasised the importance of culturally tailoredinterventions. Self-management support can be providedby many different professionals, often specialist nurses[38, 63] or LTC educators [25, 27, 95], but in some con-texts the key personnel were community health workers[35, 97] or peer counsellors [30, 56, 66]. Traditionallyeducation is delivered face-to-face, but increasinglytechnology-based interventions are being developed asalternatives [27, 28, 30, 42, 45, 47, 54, 57, 59, 62, 68].Self-management support interventions are an integral

component of high-quality care for people with LTCs[8–10]. Several of the systematic reviews demonstratedthe synergy between self-management education andregular clinical review [31, 33, 36], and supported self-management is most effective when delivered within aproactive asthma management programme [33, 37, 65],or integrated within organisational routines [50, 52].Only a minority of trials had follow-up periods over12 months, and studies are needed to confirm long-termsustainability. Costs associated with self-managementinterventions are similar to usual care.

Strengths and limitationsMeta-reviews have some intrinsic strengths and limita-tions. The methodology enables the efficient review of alarge body of evidence and thus provision of a compre-hensive overview to inform policy and practice. However,it relies on the quality of the included systematic reviews(e.g. comprehensive search strategies, accurate data ex-traction and synthesis). We used the validated R-AMSTAR instrument to assess the quality of included sys-tematic reviews [17]. In contrast to GRADE [98] (now rec-ommended by the Cochrane Handbook [15]), R-AMSTAR assesses the overall quality of the review, ratherthan assessing the quality of evidence individually for eachoutcome.Re-synthesising materials that have already been syn-

thesised risks further loss of detail and has the potentialfor erroneous assumptions, especially if the primaryfocus of the review did not directly align with the ques-tions of the meta-review. Overlap between the RCTsincluded in the systematic reviews may result in undueemphasis on commonly cited papers.Whilst some reviews and update RCTs directly com-

pared interventions with or without specific components[23–25, 32, 36, 39, 43], or a specific mode of delivery[28, 29, 41, 45], often the different interventions werecompared to usual care, allowing only indirect

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comparison [31, 33, 35, 37, 42, 46, 47]. A further limita-tion is that ‘usual care’ is rarely defined in RCTs [99],and the definition is even more unclear at meta-review level. Typically usual care is enhanced in thecontext of a trial, reducing the apparent impact of anintervention [100].Systematic reviews are only as current as their

most-recent search, and meta-reviews add anadditional time delay. In the PRISMS meta-review wetherefore not only updated our search for systematicreviews, but also searched for RCTs published afterthe date of the last search used by the includedsystematic reviews. In addition, prior to publicationwe undertook forward citation on all the includedsystematic reviews, which identified two recentsystematic reviews and six RCTs [61–68]. None ofthese changed our conclusions, confirming the matur-ity of the evidence base.The two reviewers who undertook the screening

and data extraction were not working independently;however, both projects ensured all the reviewers werefully trained and instituted random checks at everystage. Restricting inclusion to reviews with extractableRCT data maintained the quality of evidence, butmay have resulted in some lower-grade but useful evi-dence being rejected.RECURSIVE was not restricted to formal cost-

effectiveness studies – it had a broader focus and in-cluded studies reporting data on healthcare utilisationonly, without a full effectiveness analysis includingcosts and quality of life. Some of the RCTs in theRECURSIVE meta-analysis used a more comprehen-sive definition of ‘total costs’ (e.g. based on societalperspective) compared to others; to account for thisinconsistency, we also present the results on keysources of costs such as hospitalisation and A&Eattendance rates.The PRISMS and RECURSIVE teams worked inde-

pendently, but met regularly throughout the studiesto optimise synergies. A further strength was themultidisciplinary team, including backgrounds in pub-lic health, general practice, epidemiology and healthpsychology, enabling a balanced interpretation.

ConclusionsSupported self-management for asthma can reduceunscheduled care, improve asthma control and qualityof life, and does not lead to significant increases intotal healthcare costs. Effective self-managementshould be tailored to cultural, clinical and demo-graphic characteristics and is most effective whendelivered in the context of proactive LTC manage-ment. Healthcare organisations should prioritise and

promote the provision of supported self-managementfor people with asthma.

Additional files

Additional file 1: Detailed search terms: PRISMS and RECURSIVE(all databases). (DOCX 88 kb)

Additional file 2: Dates of initial and update searches. (DOCX 21 kb)

Additional file 3: Detailed PICOS table and inclusion/exclusion criteria.(DOCX 22 kb)

Additional file 4: Quality assessment and weighting. (DOCX 43 kb)

Additional file 5: Characteristics of included studies and key outcomes.(DOCX 169 kb)

AbbreviationsA&E: Accident and emergency; LTC: Long-term condition; RCTs: Randomisedcontrolled trials; SMD: Standardised mean difference

AcknowledgementsWe thank Ms Christine Hunter, lay collaborator to the PRISMS project; thePRIMER patient and public involvement group at the University of Manchester;representatives from Asthma UK; and other stakeholder groups whocontributed to the development of the project and the project workshops.

The following are members of the PRISMS group:Stephanie JC Taylor, Hilary Pinnock, Chris J Griffiths, Trisha Greenhalgh, AzizSheikh, Eleni Epiphaniou, Gemma Pearce, Hannah L Parke, AnnaSchwappach, Neetha Purushotham, Sadhana Jacob.

The following are members of the RECURSIVE group:Peter Bower, Maria Panagioti, Gerry Richardson, Elizabeth Murray, AnneRogers, Anne Kennedy, Stanton Newman, Nicola Small.

FundingPRISMS and RECURSIVE were funded by the National Institute for HealthResearch Health Services and Delivery Research Programme (projectnumbers 11/1014/04 and 11/1014/06. The funding body had no role in thedesign of the study, collection, analysis, nor interpretation of data, nor inwriting the manuscript. HP was supported by a Primary Care Research CareerAward from the Chief Scientist’s Office of the Scottish Government at thetime of the study. LD is supported by an Academic Fellowship in GeneralPractice from the Scottish School of Primary Care.

Availability of data and materialsNot applicable: all data used in this meta-review are derived from publishedstudies and thus already available.

Authors’ contributionsST and HP initiated the idea for the PRISMS study, led the development of theprotocol, securing of funding, study administration, data analysis, interpretationof results and writing of the paper. CG and AS were grant holders on thePRISMS review who contributed to the development of the protocol, thesecuring of funding, the interpretation of results and the writing of the paper.EE, HLP and GP were systematic reviewers who undertook searching, selectionof papers and data extraction with ST and HP. LD updated the PRISMS review.PB developed the idea for the RECURISVE study, secured funding and hadprimary responsibility for the interpretation of the results and writing the paper.MP and PB reviewed articles, extracted the data, undertook the data analysisand wrote the RECURSIVE paper. MP performed the RECURSIVE update for thismeta-review. All authors had full access to all the data, and were involved ininterpretation of the data. HP wrote the initial draft of the paper with HLP, LD,MP and ST to which all the authors contributed. ST and HP are study guarantorsfor PRISMS; PB and MP are study guarantors for RECURSIVE. All authors read andapproved the final manuscript.

Competing interestsThe submitted work was funded by a grant from the National Institute forHealth Research Health Services and Delivery Research Programme. None ofthe authors have financial relationships with any organisations that might

Pinnock et al. BMC Medicine (2017) 15:64 Page 29 of 32

have an interest in the submitted work. HP chairs the self-managementevidence review group for the British Thoracic Society/Scottish IntercollegiateGuideline Network Asthma guideline; the authors declare that they have noother relationships or activities that could appear to have influenced thesubmitted work.

Consent for publicationsNot applicable: no individual person’s data.

Ethics approval and consent to participateNot applicable: meta-review of published data.

Department of Health disclaimerThe views and opinions expressed therein are those of the authors and donot necessarily reflect those of the HS&DR programme, NIHR, NHS or theDepartment of Health.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Author details1Asthma UK Centre for Applied Research, Allergy and Respiratory ResearchGroup, Usher Institute of Population Health Sciences and Informatics,University of Edinburgh, Doorway 3, Medical School, Teviot Place, EdinburghEH8 9AG, UK. 2Centre for Primary Care and Public Health, Barts and TheLondon School of Medicine and Dentistry, Queen Mary University of London,London, UK. 3NIHR School for Primary Care Research, Centre for Primary Care,Manchester Academic Health Science Centre, University of Manchester,Manchester, UK. 4Centre for Technology Enabled Health Research (CTEHR),Coventry University, Coventry, UK.

Received: 28 September 2016 Accepted: 20 February 2017

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