Chronic disease management programmes for adults with asthma

Expert opinion on gray areas in asthma management: A lesson from the innovative project "revolution in asthma" of the Italian thoracic society (AIPO-ITS)

BACKGROUND

Despite the availability of numerous guidelines for asthma management, their recommendations are not consistently implemented in clinical practice. This discrepancy between guidelines and real-world practice among Italian healthcare professionals was explored during the "Revolution in Asthma" training program, which identified "gray areas" and barriers preventing clinicians from adopting guideline-based approaches.

OBJECTIVE

This study aims to analyze the key challenges in asthma management and provide evidence-based solutions to improve adherence to guidelines in clinical practice.

METHODS

A group of experts from the Scientific Committee of the Revolution in Asthma project reviewed the program's findings, focusing on three main areas of asthma management: diagnosis, control, and treatment. The experts summarized clinicians' main needs and questions for each area and provided evidence-based responses and practical recommendations.

RESULTS

The study highlights critical challenges in asthma treatment, addressing two key questions: (a) What are the possible uses and indications for short-acting β-agonists in asthma patients? (b) How should asthma treatment be initiated and adjusted based on asthma control? The expert panel developed practical, operational tools to support general practitioners and specialists (pulmonologists and allergists) in optimizing asthma management.

CONCLUSION

This paper serves as a knowledge co-creation initiative, bridging the gap between clinical guidelines and daily practice. By offering concrete recommendations, it aims to enhance the application of guideline-based asthma management among healthcare professionals.

Effectiveness of care models for chronic disease management: A scoping review of systematic reviews

OBJECTIVE

To conduct a scoping review of models of care for chronic disease management to identify potentially effective components for management of chronic traumatic brain injury (TBI).

METHODS

Information sources: Systematic searches of three databases (Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews) from January 2010 to May 2021.

ELIGIBILITY CRITERIA

Systematic reviews and meta-analyses reporting on the effectiveness of the Chronic Care Model (CCM), collaborative/integrated care, and other chronic disease management models.

DATA

Target diseases, model components used (n = 11), and six outcomes (disease-specific, generic health-related quality of life and functioning, adherence, health knowledge, patient satisfaction, and cost/health care use).

SYNTHESIS

Narrative synthesis, including proportion of reviews documenting outcome benefits.

RESULTS

More than half (55%) of the 186 eligible reviews focused on collaborative/integrated care models, with 25% focusing on CCM and 20% focusing on other chronic disease management models. The most common health conditions were diabetes (n = 22), depression (n = 16), heart disease (n = 12), aging (n = 11), and kidney disease (n = 8). Other single medical conditions were the focus of 22 reviews, multiple medical conditions of 59 reviews, and other or mixed mental health/behavioral conditions of 20 reviews. Some type of quality rating for individual studies was conducted in 126 (68%) of the reviews. Of reviews that assessed particular outcomes, 80% reported disease-specific benefits, and 57% to 72% reported benefits for the other five types of outcomes. Outcomes did not differ by the model category, number or type of components, or target disease.

CONCLUSIONS

Although there is a paucity of evidence for TBI per se, care model components proven effective for other chronic diseases may be adaptable for chronic TBI care.

MISSION ABC: transforming respiratory care through one-stop multidisciplinary clinics - an observational study

OBJECTIVES

The Modern Innovative Solutions to Improve Outcomes in Asthma, Breathlessness and Chronic Obstructive Pulmonary Disease (COPD) (MABC) service aimed to enhance disease management for chronic respiratory conditions through specialist multidisciplinary clinics, predominantly in the community. This study assesses the outcomes of these clinics.

DESIGN

This study used a prospective, longitudinal, participatory action research approach.

SETTING

The study was conducted in primary care practices across Hampshire, UK.

PARTICIPANTS

Adults aged 16 years and above with poorly controlled asthma or COPD, as well as those with undifferentiated breathlessness not under specialist care, were included.

INTERVENTIONS

Participants received care through the multidisciplinary, specialist-led MABC clinics.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes included disease activity, quality of life and healthcare utilisation. Secondary outcomes encompassed clinic attendance, diagnostic changes, patient activation, participant and healthcare professional experiences and cost-effectiveness.

RESULTS

A total of 441 participants from 11 general practitioner practices were recruited. Ninety-six per cent of participants would recommend MABC clinics. MABC assessments led to diagnosis changes for 64 (17%) participants with asthma and COPD and treatment adjustments for 252 participants (57%). Exacerbations decreased significantly from 236 to 30 after attending the clinics (p<0.005), with a mean reduction of 0.53 exacerbation events per participant. Reductions were also seen in unscheduled and out-of-hours primary care attendance, emergency department visits and hospital admissions (all p<0.005). Cost savings from reduced exacerbations and healthcare utilisation offset increased medication costs and clinic expenses.

CONCLUSIONS

Specialist-supported multidisciplinary teams in MABC clinics improved diagnosis accuracy and adherence to guidelines. High patient satisfaction, disease control improvements and reduced exacerbations resulted in decreased unscheduled healthcare use and cost savings.

TRIAL REGISTRATION NUMBER

NCT03096509.

Effectiveness and perceptions of using templates in long-term condition reviews: a systematic synthesis of quantitative and qualitative studies

Background

Review templates are commonly used in long-term condition (LTC) consultations to standardise care for patients and promote consistent data recording. However, templates may affect interactions during the review and, potentially, inhibit patient-centred care.

Aim

To systematically review the literature about the impact that LTC review templates have on process and health outcomes, and the views of health professionals and patients on using review templates in consultations.

Design and setting

Parallel qualitative and quantitative systematic reviews.

Method

Following Cochrane methodology, nine databases were searched (1995–2019; updated July 2020) for clinical trials and qualitative studies of LTC templates in healthcare settings. Duplicate selection, risk-of-bias assessment, and data extraction were performed. The quantitative and qualitative analyses were conducted in parallel, and findings synthesised narratively.

Results

In total, 12 qualitative and 14 quantitative studies were included (two studies reported both qualitative and quantitative data, and were included in both analyses). Review templates were well used, but the only study to assess health outcomes showed no effect. Templates can improve documentation of key measures and act as a reminder tool; however, they can restrict the review process, and risk health professionals’ agendas being prioritised over those of patients. Templates may also limit opportunities to discuss individuals’ concerns about living with their condition and act as a barrier to providing patient-centred care.

Conclusion

Future research should evaluate health, as well as process, outcomes. The potential benefits of templates in improving documentation should be balanced against concerns that ‘tick boxes’ may override patient agendas, unless templates are designed to promote patient-centred care.

'It's not one size fits all': a qualitative study of patients' and healthcare professionals' views of self-management for bronchiectasis

BACKGROUND

Bronchiectasis is a chronic respiratory condition that impacts significantly on individuals and healthcare services. Self-management is recommended in clinical guidelines for bronchiectasis as an intervention to enable patients to manage their condition, yet there is little evidence to support it.

METHODS

Three face to face focus groups (17 adults with bronchiectasis) were conducted at three National Health Service (NHS) sites in North West England. Additionally, semi-structured telephone interviews were undertaken with 11 healthcare professionals (HCPs), including doctors, nurses and physiotherapists. Thematic analysis identified common themes and occurrences verified by independent audit.

FINDINGS

Four common overarching themes were identified: the meaning of self-management; benefits; barriers and influencers to self-management; subthemes varied. Both groups recognised component interventions. Patients highlighted that self-management enabled them to learn what works and moderate behaviour. Aspects of delivery and structure were important to HCPs but a 'make do' culture was evident. Benefits for both groups included empowering patients. Common barriers for patients were time, mood and lack of access to support which could mitigate engagement with self-management. HCPs identified barriers including patient characteristics and lack of resources. Influencers for patients were peer, carer and psychosocial support, for HCPs influencers were individual patient attributes, including ability and motivation, and HCP characteristics such as knowledge and understanding about bronchiectasis.

SUMMARY

This is the first study to explore patients' and HCPs' views of self-management for bronchiectasis. The need for an individual, flexible and responsive self-management programme specific to bronchiectasis was evident. Personal characteristics of patients and HCPs could affect the uptake and engagement with self-management and HCPs knowledge of the disease is a recognised precursor to effective self-management. The study identified key aspects for consideration during development, delivery and sustainability of self-management programmes and findings suggest that patients' psychosocial and socioeconomic circumstances may affect adoption and activation of self-management behaviours.

Interventions to increase patient and family involvement in escalation of care for acute life-threatening illness in community health and hospital settings

BACKGROUND

There is now a rising commitment to acknowledge the role patients and families play in contributing to their safety. This review focuses on one type of involvement in safety - patient and family involvement in escalation of care for serious life-threatening conditions i.e. helping secure a step-up to urgent or emergency care - which has been receiving increasing policy and practice attention. This review was concerned with the negotiation work that patient and family members undertake across the emergency care escalation pathway, once contact has been made with healthcare staff. It includes interventions aiming to improve detection of symptoms, communication of concerns and staff response to these concerns.

OBJECTIVES

To assess the effects of interventions designed to increase patient and family involvement in escalation of care for acute life-threatening illness on patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP) ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform from 1 Jan 2000 to 24 August 2018. The search was updated on 21 October 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-randomised controlled trials where the intervention focused on patients and families working with healthcare professionals to ensure care received for acute deterioration was timely and appropriate. A key criterion was to include an interactive element of rehearsal, role play, modelling, shared language, group work etc. to the intervention to help patients and families have agency in the process of escalation of care. The interventions included components such as enabling patients and families to detect changes in patients' conditions and to speak up about these changes to staff. We also included studies where the intervention included a component targeted at enabling staff response.

DATA COLLECTION AND ANALYSIS

Seven of the eight authors were involved in screening; two review authors independently extracted data and assessed the risk of bias of included studies, with any disagreements resolved by discussion to reach consensus. Primary outcomes included patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. Our advisory group (four users and four providers) ensured that the review was of relevance and could inform policy and practice.

MAIN RESULTS

We included nine studies involving 436,684 patients and family members and one ongoing study. The published studies focused on patients with specific conditions such as coronary artery disease, ischaemic stroke, and asthma, as well as pregnant women, inpatients on medical surgical wards, older adults and high-risk patients with a history of poor self-management. While all studies tested interventions versus usual care, for four studies the usual care group also received educational or information strategies. Seven of the interventions involved face-to-face, interactional education/coaching sessions aimed at patients/families while two provided multi-component education programmes which included components targeted at staff as well as patients/families. All of the interventions included: (1) an educational component about the acute condition and preparedness for future events such as stroke or change in fetal movements: (2) an engagement element (self-monitoring, action plans); while two additionally focused on shared language or communication skills. We had concerns about risk of bias for all but one of the included studies in respect of one or more criteria, particularly regarding blinding of participants and personnel. Our confidence in results regarding the effectiveness of interventions was moderate to low. Low-certainty evidence suggests that there may be moderate improvement in patients' knowledge of acute life-threatening conditions, danger signs, appropriate care-seeking responses, and preparedness capacity between interactional patient-facing interventions and multi-component programmes and usual care at 12 months (MD 4.20, 95% CI 2.44 to 5.97, 2 studies, 687 participants). Four studies in total assessed knowledge (3,086 participants) but we were unable to include two other studies in the pooled analysis due to differences in the way outcome measures were reported. One found no improvement in knowledge but higher symptom preparedness at 12 months. The other study found an improvement in patients' knowledge about symptoms and appropriate care-seeking responses in the intervention group at 18 months compared with usual care. Low-certainty evidence from two studies, each using a different measure, meant that we were unable to determine the effects of patient-based interventions on self-efficacy. Self-efficacy was higher in the intervention group in one study but there was no difference in the other compared with usual care. We are uncertain whether interactional patient-facing and multi-component programmes improve time from the start of patient symptoms to treatment due to low-certainty evidence for this outcome. We were unable to combine the data due to differences in outcome measures. Three studies found that arrival times or prehospital delay time was no different between groups. One found that delay time was shorter in the intervention group. Moderate-certainty evidence suggests that multi-component interventions probably have little or no impact on mortality rates. Only one study on a pregnant population was eligible for inclusion in the review, which found no difference between groups in rates of stillbirth. In terms of unintended events, we found that interactional patient-facing interventions to increase patient and family involvement in escalation of care probably have few adverse effects on patient's anxiety levels (moderate-certainty evidence). None of the studies measured or reported patient and family perceptions of involvement in escalation of care or patient and family experience of patient care. Reported outcomes related to healthcare professionals were also not reported in any studies.

AUTHORS' CONCLUSIONS

Our review identified that interactional patient-facing interventions and multi-component programmes (including staff) to increase patient and family involvement in escalation of care for acute life-threatening illness may improve patient and family knowledge about danger signs and care-seeking responses, and probably have few adverse effects on patient's anxiety levels when compared to usual care. Multi-component interventions probably have little impact on mortality rates. Further high-quality trials are required using multi-component interventions and a focus on relational elements of care. Cognitive and behavioural outcomes should be included at patient and staff level.

Going mobile with primary care: smartphone-telemedicine for asthma management in young urban adults (TEAMS)

BACKGROUND

The majority of adults with persistent asthma have chronically uncontrolled disease and interventions to improve outcomes are needed. We evaluated the efficacy, feasibility, and acceptability of a multi-component smartphone-telemedicine program (TEAMS) to deliver asthma care remotely, support provider adherence to asthma management guidelines, and improve patient outcomes.

METHODS

TEAMS utilized: (1) remote symptom monitoring, (2) nurse-led smartphone-telemedicine with self-management training for patients, and (3) Electronic medical record-based clinical decision support software. Adults aged 18-44 (N = 33) and primary care providers (N = 4) were recruited from a safety-net practice in Upstate New York. Asthma control, quality of life, and FEV₁ were measured at 0, 3 and 6 months. Acceptability was assessed via survey and end-of-study interviews. Paired t-test and mixed effects modeling were used to evaluate the effect of the intervention on asthma outcomes.

RESULTS

At baseline, 80% of participants had uncontrolled asthma. By 6-months, 80% classified as well-controlled. Improvements in control and quality of life were large (d = 1.955, d = 1.579). FEV_%pred increased 4.2% (d = 1.687) with the greatest gain in males, smokers, and lower educational status. Provider adherence to national guidelines increased from 43.3% to 86.7% (CI = 22.11-64.55) and patient adherence to medication increased from 45.58% to 85.29% (CI = 14.79-64.62). Acceptability was 95.7%; In follow up interviews, 29/30 patients and all providers indicated TEAMS worked better than usual care, supported effective self-management, and reduced symptoms over time, which led to greater self-efficacy and motivation to manage asthma.

DISCUSSION

Based on these findings, we conclude that smartphone telemedicine could substantially improve clinical asthma management, adherence to guidelines, and patient outcomes.

[Integrated care management for older people with chronic diseases in domesticity: evidence from Cochrane reviews]

Hintergrund

Die Anzahl multipel chronisch erkrankter Älterer steigt, und Multimorbidität geht mit hoher Inanspruchnahme von Gesundheitsleistungen einher. Um Selbstständigkeit und Verbleib in der Häuslichkeit zu erhalten, wird zunehmend ein integriertes Versorgungsmanagement eingesetzt. Zur Wirksamkeit in der Zielgruppe der multipel chronisch erkrankten Älteren liegen aber kaum belastbare Daten vor.

Ziel der Arbeit

Bewertung der Wirksamkeit von integriertem Versorgungsmanagement bei Erwachsenen und Abschätzung der Übertragbarkeit auf ältere, multimorbide Personen in Deutschland.

Methoden

Systematische Literaturrecherche in der Cochrane Library mit Einschluss von Cochrane-Reviews (CR) zu (a) den 13 häufigsten Gesundheitsproblemen im Alter, mit (b) Komponenten des integrierten Versorgungsmanagements bei (c) Erwachsenen jeden Alters. Experten schätzten die Übertragbarkeit der eingeschlossenen CR auf multipel chronisch erkrankte Ältere in Deutschland ein.

Ergebnisse

Aus 1412 Treffern wurden 126 CR eingeschlossen. Zur Endpunktkategorie Selbstständigkeit und funktionale Gesundheit zeigten 25 CR klinisch relevante Ergebnisse mit moderater Evidenzqualität. Folgende Interventionskomponenten wurden – unter Berücksichtigung identifizierter Barrieren – als übertragbar eingeschätzt und könnten für ein effektives, indikationsspezifisch integriertes Versorgungsmanagement multipel chronisch erkrankter Älterer herangezogen werden: (1) körperliche Aktivierung, (2) multidisziplinäre Interventionen, (3) das Selbstmanagement verstärkende Interventionen, (4) kognitive Therapieverfahren, (5) telemedizinische Interventionen und (6) Disease-Management-Programme.

Schlussfolgerungen

Die identifizierten Komponenten sollten in versorgungs- und patientennahen randomisierten kontrollierten Studien auf Wirksamkeit bei gebrechlichen Älteren geprüft werden.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00391-020-01796-1) enthalten.

Publication and related bias in quantitative health services and delivery research: a multimethod study

Background

Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.

Objectives

To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.

Methods

The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).

Results

We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.

Conclusions

This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.

Study registration

This study is registered as PROSPERO CRD42016052333 and CRD42016052366.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.

Needs for Systems Approaches to Better Treat Individuals With Severe Asthma: Predicting Phenotypes and Responses to Treatments

Asthma is a frequent heterogeneous multifactorial chronic disease whose severe forms remain largely uncontrolled despite the availability of many drugs and educational therapy. Several phenotypes and endotypes of severe asthma have been described over the last two decades. Typical type-2-immunity-driven asthma remains the most frequent phenotype, and several targeted therapies have been developed and are now available. On the contrary, non-type-2 immunity-driven severe asthma is less understood and still requires efficient innovative therapies. A personalized approach would allow improving asthma control with the help of robust biomarkers able to predict phenotypes/endotypes, exacerbations, response to targeted treatments and, in the future, possible curative options. Some data from large multicenter cohorts have emerged in recent years, especially in transcriptomics. These data have to be integrated and reproduced longitudinally to provide a systems approach for asthma care. In this focused review, the needs for such an approach and the available data will be reviewed as well as the next steps for achieving personalized medicine in asthma.

Effect of involving certified healthcare assistants in primary care in Germany: a cross-sectional study

OBJECTIVES

Growing prevalence of chronic diseases and limited resources are the key challenges for future healthcare. As a promising approach to maintain high-quality primary care, non-physician healthcare professionals have been trained to broaden qualifications and responsibilities. This study aimed to assess the influence of involving certified healthcare assistants (HCAs, German: Versorgungsassistent/in in der Hausarztpraxis) on quality and efficacy of primary care in Germany.

DESIGN

Cross-sectional study.

SETTING

Primary care.

PARTICIPANTS

Patients insured by the Allgemeine Ortskrankenkasse (AOK) statutory health insurer (AOK, Baden-Wuerttemberg, Germany).

INTERVENTIONS

Since 2008 practice assistants in Germany can enhance their professional education to become certified HCAs.

PRIMARY AND SECONDARY OUTCOME MEASURES

Claims data related to patients treated in practices employing at least one HCA were compared with data from practices not employing HCAs to determine frequency of consultations, hospital admissions and readmissions. Economic analysis comprised hospitalisation costs, prescriptions of follow-on drugs and outpatient medication costs.

RESULTS

A total of 397 493 patients were treated in HCA practices, 463 730 patients attended to non-HCA practices. Patients in HCA practices had an 8.2% lower rate of specialist consultations (p<0.0001), a 4.0% lower rate of hospitalisations (p<0.0001), a 3.5% lower rate of readmissions (p=0.0463), a 14.2% lower rate of follow-on drug prescriptions (p<0.0001) and 4.7% lower costs of total medication (p<0.0001). No difference was found regarding the consultation rate of general practitioners and hospital costs.

CONCLUSIONS

For the first time, this high-volume claims data analysis showed that involving HCAs in primary care in Germany is associated with a reduction in hospital admissions, specialist consultations and medication costs. Consequently, broadening qualifications may be a successful strategy not only to share physicians' work load but to improve quality and efficacy in primary care to meet future challenges. Future studies may explore specific tasks to be shared with non-physician workforces and standardisation of the professional role.

Health-related quality of life burden in severe asthma

It is largely unrecognised that the impacts of asthma are different in patients with severe disease compared with patients with mild to moderate disease. Severe asthma is associated with a significant health-related quality of life (HRQoL) burden due to excessive symptoms, frequent and life-threatening attacks, increased comorbidity burden, and high pharmacological treatment requirements. Interventions aimed at improving HRQoL need to be specifically tested in populations with severe asthma, including multicomponent interventions targeting the many clinical characteristics associated with the disease. It is necessary to have patient-reported outcome measures developed specifically for severe asthma. Public health messages recognising the significant burden of severe asthma on quality of life are needed.

Asthma patients' perception on their care pathway: a qualitative study

Because of insufficient asthma control in many patients, the collaboration between stakeholders is regarded as a promising strategy to improve asthma outcomes. This study explored the perceptions of French adult asthma patients on their care pathway. We conducted a qualitative study based on the interviews of 30 asthma patients aged 18–40 years, recruited in French primary care. We performed a thematic analysis of the data collected, using the NVivo software. According to the patients, the stakeholders involved in asthma management included those visible to healthcare professionals (patient, general practitioner, specialist(s), pharmacist, physiotherapist, family and friends) and those concealed by the patients (complementary and alternative practitioners); other stakeholders, such as nurses and occupational physicians, were not involved. Asthma management at diagnosis and follow-up phases proved to be unstructured, and were associated with poor patient education. This was supported by patients’ ambivalence (in relation to illness and treatments), poor communication between patients and healthcare professionals (lack of listening and use of inappropriate vocabulary by physicians, underreporting of alternative medicine use by patients) and weak cooperation between professionals (limited to interaction between the general practitioner and the specialist, either pulmonologist or allergist). Asthma management would probably benefit from a more coordinated care pathway at each phase of the disease that is consistent with the expectations and goals of the patients. It should be based on improved organization (involvement of other healthcare professionals and the patient as partners) and processes (regular follow-up, specific tools such as peak flow meter or action plan).

Impact of non-drug therapies on asthma control: A systematic review of the literature

BACKGROUND

Despite growing access to effective therapies, asthma control still needs improvement. Many non-drug factors, such as allergens, air pollutants and stress also affect asthma control and patient quality of life, but an overview of the effectiveness of non-drug interventions on asthma control was lacking.

OBJECTIVES

To identify non-drug interventions likely to improve asthma control.

METHODS

A systematic review of the available literature in Medline and the Cochrane Library was conducted in March 2017, without any time limit. Initial searching identified 884 potentially relevant clinical trial reports, literature reviews and meta-analyses, which were screened for inclusion using criteria of quality, relevance, and reporting outcomes based on asthma control.

RESULTS

Eighty-two publications met the inclusion criteria. In general, the quality of the studies was low. Patient education programmes (22 studies) significantly improved asthma control. Multifaceted interventions (10 studies), which combined patient education programmes with decreasing exposure to indoor allergens and pollutants, significantly improved asthma control based on clinically relevant outcomes. Renovating homes to reduce exposure to allergens and indoor pollutants improved control (two studies). Air filtration systems (five studies) were effective, especially in children exposed to second-hand smoke. Most measures attempting to reduce exposure to dust mites were ineffective (five studies). Dietary interventions (eight studies) were ineffective. Promoting physical activity (five studies) tended to yield positive results, but the results did not attain significance.

CONCLUSION

Twenty-six interventions were effective in asthma control. Simultaneously combining several action plans, each focusing on different aspects of asthma management, seems most likely to be effective.

Perspectives of people with aphasia post-stroke towards personal recovery and living successfully: A systematic review and thematic synthesis

BACKGROUND

There is increased focus on supporting people with chronic conditions to live well via person-centred, integrated care. There is a growing body of qualitative literature examining the insider perspectives of people with post-stroke aphasia (PWA) on topics relating to personal recovery and living successfully (PR-LS). To date no synthesis has been conducted examining both internal and external, structural influences on living well. In this study, we aimed to advance theoretical understanding of how best to promote and support PR-LS by integrating the perspectives of PWA on a wide range of topics relating to PR-LS. This is essential for planning and delivering quality care.

METHODS AND FINDINGS

We conducted a systematic review, following PRISMA guidelines, and thematic synthesis. Following a search of 7 electronic databases, 31 articles were included and critically appraised using predetermined criteria. Inductive and iterative analysis generated 5 analytical themes about promoting PR-LS. Aphasia occurs in the context of a wider social network that provides valued support and social companionship and has its own need for formal support. PWA want to make a positive contribution to society. The participation of PWA is facilitated by enabling environments and opportunities. PWA benefit from access to a flexible, responsive, life-relevant range of services in the long-term post-stroke. Accessible information and collaborative interactions with aphasia-aware healthcare professionals empower PWA to take charge of their condition and to navigate the health system.

CONCLUSION

The findings highlight the need to consider wider attitudinal and structural influences on living well. PR-LS are promoted via responsive, long-term support for PWA, friends and family, and opportunities to participate autonomously and contribute to the community. Shortcomings in the quality of the existing evidence base must be addressed in future studies to ensure that PWA are meaningfully included in research and service development initiatives.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews PROSPERO 2017: CRD42017056110.

Interventions to Support Behavioral Self-Management of Chronic Diseases

A majority of the US adult population has one or more chronic conditions that require medical intervention and long-term self-management. Such conditions are among the 10 leading causes of mortality; an estimated 86% of the nation's $2.7 trillion in annual health care expenditures goes toward their treatment and management. Patient self-management of chronic diseases is increasingly essential to improve health behaviors, health outcomes, and quality of life and, in some cases, has demonstrated effectiveness for reducing health care utilization and the societal cost burden of chronic conditions. This review synthesizes the current state of the science of chronic disease self-management interventions and the evidence for their effectiveness, especially when applied with a systematic application of theories or models that account for a wide range of influences on behavior. Our analysis of selected outcomes from randomized controlled trials of chronic disease self-management interventions contained in 10 Cochrane systematic reviews provides additional evidence to demonstrate that self-management can improve quality of life and reduce utilization across several conditions.

Patient-mediated interventions to improve professional practice

BACKGROUND

Healthcare professionals are important contributors to healthcare quality and patient safety, but their performance does not always follow recommended clinical practice. There are many approaches to influencing practice among healthcare professionals. These approaches include audit and feedback, reminders, educational materials, educational outreach visits, educational meetings or conferences, use of local opinion leaders, financial incentives, and organisational interventions. In this review, we evaluated the effectiveness of patient-mediated interventions. These interventions are aimed at changing the performance of healthcare professionals through interactions with patients, or through information provided by or to patients. Examples of patient-mediated interventions include 1) patient-reported health information, 2) patient information, 3) patient education, 4) patient feedback about clinical practice, 5) patient decision aids, 6) patients, or patient representatives, being members of a committee or board, and 7) patient-led training or education of healthcare professionals.

OBJECTIVES

To assess the effectiveness of patient-mediated interventions on healthcare professionals' performance (adherence to clinical practice guidelines or recommendations for clinical practice).

SEARCH METHODS

We searched MEDLINE, Ovid in March 2018, Cochrane Central Register of Controlled Trials (CENTRAL) in March 2017, and ClinicalTrials.gov and the International Clinical Trials Registry (ICTRP) in September 2017, and OpenGrey, the Grey Literature Report and Google Scholar in October 2017. We also screened the reference lists of included studies and conducted cited reference searches for all included studies in October 2017.

SELECTION CRITERIA

Randomised studies comparing patient-mediated interventions to either usual care or other interventions to improve professional practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We calculated the risk ratio (RR) for dichotomous outcomes using Mantel-Haenszel statistics and the random-effects model. For continuous outcomes, we calculated the mean difference (MD) using inverse variance statistics. Two review authors independently assessed the certainty of the evidence (GRADE).

MAIN RESULTS

We included 25 studies with a total of 12,268 patients. The number of healthcare professionals included in the studies ranged from 12 to 167 where this was reported. The included studies evaluated four types of patient-mediated interventions: 1) patient-reported health information interventions (for instance information obtained from patients about patients' own health, concerns or needs before a clinical encounter), 2) patient information interventions (for instance, where patients are informed about, or reminded to attend recommended care), 3) patient education interventions (intended to increase patients' knowledge about their condition and options of care, for instance), and 4) patient decision aids (where the patient is provided with information about treatment options including risks and benefits). For each type of patient-mediated intervention a separate meta-analysis was produced.Patient-reported health information interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 26 (95% CI 23 to 30) are in accordance with recommended clinical practice compared to 17 per 100 in the comparison group (no intervention or usual care). We are uncertain about the effect of patient-reported health information interventions on desirable patient health outcomes and patient satisfaction (very low-certainty evidence). Undesirable patient health outcomes and adverse events were not reported in the included studies and resource use was poorly reported.Patient information interventions may improve healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 42) are in accordance with recommended clinical practice compared to 20 per 100 in the comparison group (no intervention or usual care). Patient information interventions may have little or no effect on desirable patient health outcomes and patient satisfaction (low-certainty evidence). We are uncertain about the effect of patient information interventions on undesirable patient health outcomes because the certainty of the evidence is very low. Adverse events and resource use were not reported in the included studies.Patient education interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 46 (95% CI 39 to 54) are in accordance with recommended clinical practice compared to 35 per 100 in the comparison group (no intervention or usual care). Patient education interventions may slightly increase the number of patients with desirable health outcomes (low-certainty evidence). Undesirable patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.Patient decision aid interventions may have little or no effect on healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 43) are in accordance with recommended clinical practice compared to 37 per 100 in the comparison group (usual care). Patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.

AUTHORS' CONCLUSIONS

We found that two types of patient-mediated interventions, patient-reported health information and patient education, probably improve professional practice by increasing healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We consider the effect to be small to moderate. Other patient-mediated interventions, such as patient information may also improve professional practice (low-certainty evidence). Patient decision aids may make little or no difference to the number of healthcare professionals' adhering to recommended clinical practice (low-certainty evidence).The impact of these interventions on patient health and satisfaction, adverse events and resource use, is more uncertain mostly due to very low certainty evidence or lack of evidence.

Mobile Health to Maintain Continuity of Patient-Centered Care for Chronic Kidney Disease: Content Analysis of Apps

BACKGROUND

Chronic kidney disease (CKD) is a global health problem with a high economic burden, which is particularly prevalent in Taiwan. Mobile health apps have been widely used to maintain continuity of patient care for various chronic diseases. To slow the progression of CKD, continuity of care is vital for patients' self-management and cooperation with health care professionals. However, the literature provides a limited understanding of the use of mobile health apps to maintain continuity of patient-centered care for CKD.

OBJECTIVE

This study identified apps related to the continuity of patient-centered care for CKD on the App Store, Google Play, and 360 Mobile Assistant, and explored the information and frequency of changes in these apps available to the public on different platforms. App functionalities, like patient self-management and patient management support for health care professionals, were also examined.

METHODS

We used the CKD-related keywords "kidney," "renal," "nephro," "chronic kidney disease," "CKD," and "kidney disease" in traditional Chinese, simplified Chinese, and English to search 3 app platforms: App Store, Google Play, and 360 Mobile Assistant. A total of 2 reviewers reached consensus on coding guidelines and coded the contents and functionalities of the apps through content analysis. After coding, Microsoft Office Excel 2016 was used to calculate Cohen kappa coefficients and analyze the contents and functionalities of the apps.

RESULTS

A total of 177 apps related to patient-centered care for CKD in any language were included. On the basis of their functionality and content, 67 apps were recommended for patients. Among them, the most common functionalities were CKD information and CKD self-management (38/67, 57%), e-consultation (17/67, 25%), CKD nutrition education (16/67, 24%), and estimated glomerular filtration rate (eGFR) calculators (13/67, 19%). In addition, 67 apps were recommended for health care professionals. The most common functionalities of these apps were comprehensive clinical calculators (including eGFR; 30/67; 45%), CKD medical professional information (16/67, 24%), stand-alone eGFR calculators (14/67, 21%), and CKD clinical decision support (14/67, 21%). A total of 43 apps with single- or multiple-indicator calculators were found to be suitable for health care professionals and patients. The aspects of patient care apps intended to support self-management of CKD patients were encouraging patients to actively participate in health care (92/110, 83.6%), recognizing and effectively responding to symptoms (56/110, 50.9%), and disease-specific knowledge (53/110, 48.2%). Only 13 apps contained consulting management functions, patient management functions or teleconsultation functions designed to support health care professionals in CKD patient management.

CONCLUSIONS

This study revealed that the continuity of patient-centered care for CKD provided by mobile health apps is inadequate for both CKD self-management by patients and patient care support for health care professionals. More comprehensive solutions are required to enhance the continuity of patient-centered care for CKD.

Self-management for bronchiectasis

BACKGROUND

Bronchiectasis is a long term respiratory condition with an increasing rate of diagnosis. It is associated with persistent symptoms, repeated infective exacerbations, and reduced quality of life, imposing a burden on individuals and healthcare systems. The main aims of therapeutic management are to reduce exacerbations and improve quality of life. Self-management interventions are potentially important for empowering people with bronchiectasis to manage their condition more effectively and to seek care in a timely manner. Self-management interventions are beneficial in the management of other airways diseases such as asthma and COPD (chronic obstructive pulmonary disease) and have been identified as a research priority for bronchiectasis.

OBJECTIVES

To assess the efficacy, cost-effectiveness and adverse effects of self-management interventions for adults and children with non-cystic fibrosis bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Specialised Register of trials, clinical trials registers, reference lists of included studies and review articles, and relevant manufacturers' websites up to 13 December 2017.

SELECTION CRITERIA

We included all randomised controlled trials of any duration that included adults or children with a diagnosis of non-cystic fibrosis bronchiectasis assessing self-management interventions delivered in any form. Self-management interventions included at least two of the following elements: patient education, airway clearance techniques, adherence to medication, exercise (including pulmonary rehabilitation) and action plans.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened searches, extracted study characteristics and outcome data and assessed risk of bias for each included study. Primary outcomes were, health-related quality of life, exacerbation frequency and serious adverse events. Secondary outcomes were the number of participants admitted to hospital on at least one occasion, lung function, symptoms, self-efficacy and economic costs. We used a random effects model for analyses and standard Cochrane methods throughout.

MAIN RESULTS

Two studies with a total of 84 participants were included: a 12-month RCT of early rehabilitation in adults of mean age 72 years conducted in two centres in England (UK) and a six-month proof-of-concept RCT of an expert patient programme (EPP) in adults of mean age 60 years in a single regional respiratory centre in Northern Ireland (UK). The EPP was delivered in group format once a week for eight weeks using standardised EPP materials plus disease-specific education including airway clearance techniques, dealing with symptoms, exacerbations, health promotion and available support. We did not find any studies that included children. Data aggregation was not possible and findings are reported narratively in the review.For the primary outcomes, both studies reported health-related quality of life, as measured by the St George's Respiratory Questionnaire (SGRQ), but there was no clear evidence of benefit. In one study, the mean SGRQ total scores were not significantly different at 6 weeks', 3 months' and 12 months' follow-up (12 months mean difference (MD) -10.27, 95% confidence interval (CI) -45.15 to 24.61). In the second study there were no significant differences in SGRQ. Total scores were not significantly different between groups (six months, MD 3.20, 95% CI -6.64 to 13.04). We judged the evidence for this outcome as low or very low. Neither of the included studies reported data on exacerbations requiring antibiotics. For serious adverse events, one study reported more deaths in the intervention group compared to the control group, (intervention: 4 of 8, control: 2 of 12), though interpretation is limited by the low event rate and the small number of participants in each group.For our secondary outcomes, there was no evidence of benefit in terms of frequency of hospital admissions or FEV1 L, based on very low-quality evidence. One study reported self-efficacy using the Chronic Disease Self-Efficacy scale, which comprises 10 components. All scales showed significant benefit from the intervention but effects were only sustained to study endpoint on the Managing Depression scale. Further details are reported in the main review. Based on overall study quality, we judged this evidence as low quality. Neither study reported data on respiratory symptoms, economic costs or adverse events.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether self-management interventions benefit people with bronchiectasis. In the absence of high-quality evidence it is advisable that practitioners adhere to current international guidelines that advocate self-management for people with bronchiectasis.Future studies should aim to clearly define and justify the specific nature of self-management, measure clinically important outcomes and include children as well as adults.

The Calgary COPD & Asthma Program: The role of the respiratory therapy profession in primary care

Respiratory therapy is a profession with the depth and breadth required to care for clients by "evaluating, treating, and maintaining cardiopulmonary (heart and lung) function" [1]. Registered Respiratory Therapists (RRTs) work in a variety of settings from critical and acute care to primary and home care. After a brief overview of the models and competencies that underpin the work of the Calgary COPD & Asthma Program, the article provides a description of the program and discuss how RRT Certified Respiratory Educators provide services within the program. These services include health promotion through self-management education rooted in the Chronic Care Model [2] and supported by the National Alliance of Respiratory Therapy Regulatory Bodies' National Competency Framework for the Profession of Respiratory Therapy [3]. The authors hope the success of this program will encourage others to embrace the role of the RRT in a primary health care setting.

[Critical view and argumentation on chronic care programs in Primary and Community Care]

El análisis detallado de los planes de atención a la cronicidad desarrollados por los servicios regionales de salud pone de manifiesto un sorprendente nivel de uniformidad en su diseño y despliegue, a pesar de las diferencias existentes entre dichos servicios. La revisión de la literatura sobre los modelos teóricos que lo sustentan y los instrumentos que lo desarrollan no aporta evidencias concluyentes que permitan afirmar que los modelos de atención a pacientes crónicos alcanzan mejores resultados que modelos de atención alternativos. A pesar de que todos los planes de atención a la cronicidad incluyen sistemas de evaluación de los mismos, no se han publicado hasta la fecha estudios rigurosos sobre su efecto.

Dado que, por el contrario, sí existen pruebas sólidas y reiteradas de que modelos con una Atención Primaria fuerte obtienen mejores resultados, cabe preguntarse sobre la necesidad de buscar modelos alternativos, cuando las metas propuestas probablemente podrían alcanzarse de fortalecer realmente la Atención Primaria.

Personalised asthma action plans for adults with asthma

BACKGROUND

A key aim of asthma care is to empower each person to take control of his or her own condition. A personalised asthma action plan (PAAP), also known as a written action plan, an individualised action plan, or a self-management action plan, contributes to this endeavour. A PAAP includes individualised self-management instructions devised collaboratively with the patient to help maintain asthma control and regain control in the event of an exacerbation. A PAAP includes baseline characteristics (such as lung function), maintenance medication and instructions on how to respond to increasing symptoms and when to seek medical help.

OBJECTIVES

To evaluate the effectiveness of PAAPs used alone or in combination with education, for patient-reported outcomes, resource use and safety among adults with asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials, clinical trial registers, reference lists of included studies and review articles, and relevant manufacturers' websites up to 14 September 2016.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs), both blinded and unblinded, that evaluated written PAAPs in adults with asthma. Included studies compared PAAP alone versus no PAAP, and/or PAAP plus education versus education alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted study characteristics and outcome data and assessed risk of bias for each included study. Primary outcomes were number of participants reporting at least one exacerbation requiring an emergency department (ED) visit or hospitalisation, asthma symptom scores on a validated scale and adverse events (all causes). Secondary outcomes were quality of life measured on a validated scale, number of participants reporting at least one exacerbation requiring systemic corticosteroids, respiratory function and days lost from work or study. We used a random-effects model for all analyses and standard Cochrane methods throughout.

MAIN RESULTS

We identified 15 studies described in 27 articles that met our inclusion criteria. These 15 included studies randomised a total of 3062 participants (PAAP vs no PAAP: 2602 participants; PAAP plus education vs education alone: 460 participants). Ten studies (eight PAAP vs no PAAP; two PAAP plus education vs education alone) provided outcome data that contributed to quantitative analyses. The overall quality of evidence was rated as low or very low.Fourteen studies lasted six months or longer, and the remaining study lasted for 14 weeks. When reported, mean age ranged from 22 to 49 years and asthma severity ranged from mild to severe/high risk. PAAP alone compared with no PAAPResults showed no clear benefit or harm associated with PAAPs in terms of the number of participants requiring an ED visit or hospitalisation for an exacerbation (odds ratio (OR) 0.75, 95% confidence interval (CI) 0.45 to 1.24; 1385 participants; five studies; low-quality evidence), change from baseline in asthma symptoms (mean difference (MD) -0.16, 95% CI -0.25 to - 0.07; 141 participants; one study; low-quality evidence) or the number of serious adverse events, including death (OR 3.26, 95% CI 0.33 to 32.21; 125 participants; one study; very low-quality evidence). Data revealed a statistically significant improvement in quality of life scores for those receiving PAAP compared with no PAAP (MD 0.18, 95% CI 0.05 to 0.30; 441 participants; three studies; low-quality evidence), but this was below the threshold for a minimum clinically important difference (MCID). Results also showed no clear benefit or harm associated with PAAPs on the number of participants reporting at least one exacerbation requiring oral corticosteroids (OR 1.45, 95% CI 0.84 to 2.48; 1136 participants; three studies; very low-quality evidence) nor on respiratory function (change from baseline forced expiratory volume in one second (FEV1): MD -0.04 L, 95% CI -0.25L to 0.17 L; 392 participants; three studies; low-quality evidence). In one study, PAAPs were associated with significantly fewer days lost from work or study (MD -6.20, 95% CI -7.32 to - 5.08; 74 participants; low-quality evidence). PAAP plus education compared with education aloneResults showed no clear benefit or harm associated with adding a PAAP to education in terms of the number of participants requiring an ED visit or hospitalisation for an exacerbation (OR 1.08, 95% CI 0.27 to 4.32; 70 participants; one study; very low-quality evidence), change from baseline in asthma symptoms (MD -0.10, 95% CI -0.54 to 0.34; 70 participants; one study; low-quality evidence), change in quality of life scores from baseline (MD 0.13, 95% CI -0.13 to 0.39; 174 participants; one study; low-quality evidence) and number of participants requiring oral corticosteroids for an exacerbation (OR 0.28, 95% CI 0.07 to 1.12; 70 participants; one study; very low-quality evidence). No studies reported serious adverse events, respiratory function or days lost from work or study.

AUTHORS' CONCLUSIONS

Analysis of available studies was limited by variable reporting of primary and secondary outcomes; therefore, it is difficult to draw firm conclusions related to the effectiveness of PAAPs in the management of adult asthma. We found no evidence from randomised controlled trials of additional benefit or harm associated with use of PAAP versus no PAAP, or PAAP plus education versus education alone, but we considered the quality of the evidence to be low or very low, meaning that we cannot be confident in the magnitude or direction of reported treatment effects. In the context of this caveat, we found no observable effect on the primary outcomes of hospital attendance with an asthma exacerbation, asthma symptom scores or adverse events. We recommend further research with a particular focus on key patient-relevant outcomes, including exacerbation frequency and quality of life, in a broad spectrum of adults, including those over 60 years of age.

Impact of Adding a Decision Aid to Patient Education in Adults with Asthma: A Randomized Clinical Trial

BACKGROUND

Not providing adequate patient education interventions to asthma patients remains a major care gap. To help asthma patients and caregivers discuss inhaled controller medication use, our team has previously developed a decision aid (DA). We sought to assess whether adding this DA to education interventions improved knowledge, decisional conflict, and asthma control among adults with asthma.

METHODS

A parallel clinical trial (NCT02516449). We recruited adults with asthma, aged 18 to 65 years, prescribed inhaled controller medication to optimize asthma control. Educators randomly allocated participants either to the education + DA or to the education group. At baseline and two-month follow-up, we measured asthma knowledge (primary outcome) with a validated self-administered questionnaire (score -37 to +37). Secondary outcomes included decisional conflict and asthma control. Blinded assessors collected data. Between the two time points, the within- and between-group changes were estimated by generalized linear mixed models.

RESULTS

Fifty-one participants (response rate: 53%; age: 44 ± 13 years; women: n = 32) were randomized either to the education + DA group (n = 26) or to the education group (n = 25), and included in statistical analyses. Between baseline and follow-up, mean [95% CI] knowledge scores increased from 21.5 [19.9-23.2] to 25.1 [23.1-27.0] in the education + DA group (P = 0.0002) and from 24.0 [22.3-25.7] to 26.0 [24.0-28.0] in the education group (P = 0.0298). In both of the groups, decisional conflict and asthma control improved. There were no differences between groups.

CONCLUSIONS

Education improved knowledge, decisional conflict, and asthma control whether the DA was added or not.

Measurement Reactivity in a Randomized Clinical Trial Using Self-Reported Data

PURPOSE

The objective of this article is to describe how self-monitoring contributed to measurement reactivity in a randomized clinical trial (RCT). The implications of measurement reactivity on self-monitoring and suggestions for minimizing its effect will be discussed.

DESIGN

The study involved a secondary data analysis of responses from 145 participants who completed a 12-month long RCT. The original sample consisted of 202 community-living adults with long-term indwelling urinary catheters.

METHODS

The data analyzed were from the participants' brief responses to the final study question concerning their perceived study participation value. The data were discussed and coded iteratively until three researchers reached consensus. At the end, each item was recoded into eight categories and minor codes.

FINDINGS

Our belief that the calendar was the probable cause of reactivity was not fully supported as the control group also learned about paying attention to urinary catheter problems by the questions asked through the seven bimonthly interviews.

CONCLUSIONS

The calendar and interview questions were reactive by increasing participants' self-monitoring of catheter problems. Specifically, the frequent interviews exposed participants to catheter-related concerns and provided them with ideas as to how to better manage them.

CLINICAL RELEVANCE

This article provides insight related to the internal validity threat of measurement reactivity in RCTs and gives suggestions to reduce its effects.

Adding non-randomised studies to a Cochrane review brings complementary information for healthcare stakeholders: an augmented systematic review and meta-analysis

Background

To reduce the burden of asthma, chronic disease management (CDM) programmes have been widely implemented and evaluated. Reviews including randomised controlled trials (RCTs) suggest that CDM programmes for asthma are effective. Other study designs are however often used for pragmatic reasons, but excluded from these reviews because of their design. We aimed to examine what complementary information could be retrieved from the addition of non-randomised studies to the studies included in a published Cochrane review on asthma CDM programmes, for healthcare stakeholders involved in the development, implementation, conduct or long-term sustainability of such programmes.

Methods

Extending a previously published Cochrane review, we performed a systematic review (augmented review) including any type of study designs instead of only those initially accepted by Cochrane and the Effective Practice and Organization of Care Review group. After double data selection and extraction, we compared study and intervention characteristics, assessed methodological quality and ran meta-analyses, by study design.

Results

We added 37 studies to the 20 studies included in the Cochrane review. The applicability of results was increased because of the larger variety of settings and asthma population considered. Also, adding non-randomised studies provided new evidence of improvements associated with CDM intervention (i.e. healthcare utilisation, days off work, use of action plan). Finally, evidence of CDM effectiveness in the added studies was consistent with the Cochrane review in terms of direction of effects.

Conclusions

The evidence of this augmented review is applicable to a broader set of patients and settings than those in the original Cochrane review. It also strengthens the message that CDM programmes have a beneficial effect on quality of life and disease severity, meaningful outcomes for the everyday life of patients with asthma. Despite the moderate to low methodological quality of all studies included, calling for caution in results interpretation and improvements in CDM evaluation methods and reporting, the inclusion of a broader set of study designs in systematic reviews of complex interventions, such as chronic disease management, is likely to be of high value and interest to patients, policymakers and other healthcare stakeholders.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1816-5) contains supplementary material, which is available to authorized users.