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