Comparative Efficacy of Strategies to Support Self-Management in Patients with Asthma: A Systematic Review and Network Meta-Analysis

The emerging role of digital health in the management of asthma

The most common reasons seen for lack of asthma control include misconceptions about disease control, low controller treatment adherence, poor inhaler technique, and the resulting underuse of controllers and overuse of short-acting beta2 agonists (SABAs). Narrowing these care gaps may be achieved through well-designed patient education that considers the patient's motivation, beliefs, and capabilities regarding their asthma and its management and empowers the patient to become an active participant in treatment decisions. Digital health technologies (DHTs) and digital therapeutic (DT) devices provide new opportunities to monitor treatment behaviors, improve communication between healthcare providers and patients, and generate data that inform educational interactions. DHT and DT have been proven effective in enhancing patient self-management in other chronic conditions, particularly diabetes. Accelerated integration of DHT and DT into the management of asthma patients is facilitated by the use of digital inhalers that employ sensor technology ("smart" inhalers). These devices efficiently provide real-time feedback on controller adherence, SABA use, and inhaler technique that have the strong potential to optimize asthma control.

Characterizing health services interventions for evidence syntheses by using the theme, intensity, provider/platform (TIP) framework

Health services interventions comprise a range of elements and procedures that contribute to their effects. However, there is currently limited guidance to systematically classify different features of health services interventions. We propose an approach to aid in classifying health services interventions using three potential elements: theme, intensity, and provider/platform (TIP). We designed the TIP framework to be analogous to three elements of a medication intervention that contribute to its pharmaceutical effects: 1) active ingredient, 2) dose, and 3) dosage form or route of administration. Health services interventions encompass similar elements: 1) "theme", which corresponds to the active ingredient and specifies the main element of the intervention; 2) "intensity", which corresponds to the dose regimen; and 3) "provider" or "platform", which corresponds to the dosage form or route of administration and indicates how the main element is delivered. Each health services intervention can be classified into a set of unique TIP features, which can then be compared with others using either a qualitative or qualitative approach. The TIP framework is not suitable for multicomponent health services interventions, in which a singular main theme or active component cannot be identified. The TIP framework enables researchers to systematically characterize health services interventions according to their unique features that contribute to its effects. It also helps to generate evidence to determine not only what service is more effective, but also how to best deliver such service.

Clinical Outcomes of Different Warfarin Self-Care Strategies: A Systematic Review and Network Meta-Analysis

AIM

To compare the effects of different strategies for warfarin self-care.

METHODS

PubMed, EMBASE, CENTRAL, CINAHL, ProQuest Dissertations & Theses, and OpenGrey were searched from inception to August 2021. Randomized controlled trials (RCTs) of warfarin self-care, either patient self-testing (PST) or patient self-management (PSM), were included. Self-care approaches were classified based on the TIP framework (theme, intensity, provider): (1) PST ≥1/week via e-Health (PST/High/e-Health); (2) PST ≥1/week by health care practitioner (PST/High/HCP); (3) PST <1/week via e-Health (PST/Low/e-Health); (4) PSM ≥1/week by e-Health (PSM/High/e-Health); (5) PSM ≥1/week by patient (PSM/High/Pt); (6) PSM <1/week by patient (PSM/Low/Pt); and (7) PSM with flexible frequency by patient (PSM/Flex/Pt). Mean differences (MDs) and risk ratios (RRs) with 95% confidence interval (CI) were estimated using frequentist network meta-analyses with a random-effects model. The certainty of evidence was evaluated using CINeMA (Confidence in Network Meta-Analysis).

RESULTS

Sixteen RCTs involving 5,895 participants were included. When compared with usual care, time in therapeutic range was higher in PSM/High/Pt and PST/High/e-Health with MD [95% CI] of 7.67% [0.26-15.08] and 5.65% [0.04-11.26], respectively. The certainty of evidence was rated as moderate for these findings. The risk of thromboembolic events was lower in the PSM/Flex/Pt group when compared with PST/High/e-Health (RR: 0.39 [0.20-0.77]) and usual care (RR: 0.38 [0.17-0.88]) with low and very low level of evidence, respectively. There was no significant difference in the proportion of international normalized ratio (INR) values in range, major bleeding, and all-cause mortality among different self-care features.

CONCLUSION

Patient self-care (either PST or PSM) by measuring INR values at least once weekly is more effective in controlling the INR level.