psycho-educational interventions for adults with severe or difficult asthma: a systematic review

Journal of Asthma, 44:219–241, 2007Copyright C© 2007 Informa HealthcareISSN: 0277-0903 print / 1532-4303 onlineDOI: 10.1080/02770900601182012

ORIGINAL ARTICLE

Psycho-Educational Interventions for Adults with Severe or DifficultAsthma: A Systematic Review

JANE R. SMITH,∗,1 MIRANDA MUGFORD,1 RICHARD HOLLAND,1 MICHAEL J. NOBLE,2 AND BRIAN D. W. HARRISON1

1School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, United Kingdom2Acle Medical Centre, Acle, Norfolk, United Kingdom

Research highlights psychosocial factors associated with adverse asthma events. This systematic review therefore examined whether psycho-educational interventions improve health and self-management outcomes in adults with severe or difficult asthma. Seventeen controlled studies wereincluded. Characteristics and content of interventions varied even within broad types. Study quality was generally poor and several studies were small.Any positive effects observed from qualitative and quantitative syntheses were mainly short term and, in planned subgroup analyses (involving <5trials), effects on hospitalizations, quality of life, and psychological morbidity in patients with severe asthma did not extend to those in whom multiplefactors complicate management.

Keywords severe asthma, difficult asthma, adults, psycho-educational intervention, systematic review

INTRODUCTION

A significant minority of asthma patients have severeor poorly controlled disease resulting in daily symptoms,reduced quality of life, absences from work, and frequentuse of health services (1). When persistent despite medicalmanagement according to guidelines (2), this is sometimesreferred to as “difficult” asthma (3–5), which encompassesclinical subgroups with brittle, refractory, or therapy-resistant disease (3–7) and is estimated to affect less than10% of patients (1, 3, 5, 7).

The UK burden of severe, poorly controlled, and difficultasthma is most evident in the 1,400 deaths and over 70,000hospital admissions attributable to asthma anually (1). Thesecontribute to a disproportionate share of asthma-related costs(8), with half the costs stemming from the 10% of patients ex-periencing the highest morbidity and three quarters resultingfrom uncontrolled disease (9).

Various pathophysiological mechanisms are suggested tounderlie severe and difficult asthma (3, 5, 6). Increasingly,patient-related factors are also implicated (10). Studies (11–16) identify adverse behavioral/psychological characteristicsand social problems as the major potentially modifiable fac-tors associated with fatal and near-fatal asthma. Psychoso-cial problems also appear common among hospitalized pa-tients (16, 17) and those with brittle asthma (6). Relationshipsbetween psychosocial factors and asthma are complex andtwo-way: symptoms and attacks affect psychosocial well-being, while psychosocial factors can affect asthma via neu-

The initial review was funded by the UK Dept. of Health, HealthTechnology Assessment Programme (project: 01/16/02 http://www.ncchta.org/project.asp?PjtId=1251). The opinions and conclusions ex-pressed do not necessarily reflect those of the NHS or Dept. of Health.

∗Corresponding author: Jane R. Smith, School of Medicine, HealthPolicy and Practice, University of East Anglia, Norwich, UK; E-mail:[email protected]

roimmunological pathways and by influencing adherence andother self-management behaviors (10).

Psycho-educational programs involving education, train-ing in self-management, and/or targeting psychosocial is-sues resulting from or affecting asthma are increasingly ad-vocated. A Cochrane review of 36 trials (18) suggests thatinteractive self-management education improves health out-comes in general adult asthma populations. A meta-analysisof a broader range of psycho-educational interventions con-cluded that they are effective (19). However, a Cochrane re-view of psychotherapeutic interventions for asthma identifieda lack of good evidence (20) and a systematic review of re-laxation techniques found limited effects (21).

Patients in whom clinical and psychosocial factors com-plicate management, including those with severe or difficultasthma, tend to be excluded by design or default from stud-ies of psycho-educational interventions summarized in mostexisting reviews (18–21). It is thus unclear whether evidenceis likely to be generalizable to this group. A previous re-view focussed specifically on “high risk” asthma patientsdiscussed eight education programs in adults and children(22) but failed to provide definitions of relevant patients orinterventions, describe review methods, or formally synthe-size and appraise results. A Cochrane review of educationalinterventions for adults attending the emergency room forasthma remains in protocol form (23), and data on broaderpsycho-educational interventions in a range of “at-risk” pa-tients have not been formally summarized. However, this isimportant, given contradictory assertions regarding whetherinterventions are likely to be more effective, given greatercapacity to benefit (8, 22), or less effective, given potentialpsychosocial barriers to education and behavior change (10,17, 24), in these patients.

We therefore conducted a systematic review using recom-mended methods (25) to assess whether a range of psycho-educational interventions improves outcomes for adults withsevere or difficult asthma and in doing so identify options for

219

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220 J. R. SMITH ET AL.

best practice and areas for further research. This forms part of,and updates, a broader review conducted in 2002–2003 (26).

METHODS

SearchingThirty-two health-related electronic data sources (includ-

ing standard bibliographic indices, research registers, greyliterature and non-English language databases), study refer-ence lists, abstracts from 16 recent conferences, current con-tents from 81 journals, and the last 5 years of past issues ofthree key journals (Thorax, Journal of Asthma, Patient Edu-cation and Counseling) were initially searched during 2002.Further detail on these and the complex permutations of termsand headings used to search for asthma-related educational,self-management, psychosocial, and multi-faceted interven-tions is provided elsewhere (26). Update searches of six keybibliographic databases (Medline, Embase, Cumulative In-dex of Nursing & Allied Health Literature, PsycInfo, Web ofKnowledge Science & Social Science Citation Indices andApplied Social Science Index & Abstracts), chosen on thebasis that non-indexed, unpublished, and foreign languageliterature identified from other sources did not contribute tothe syntheses of high-quality research in the initial review(26), were conducted to the end of 2005.

Study Screening and SelectionTitles were screened to exclude obviously irrelevant pa-

pers. A second reviewer repeated searching and screeningfor one year (1999) across three primary databases to checkthe validity of screening procedures, which suggested that norelevant studies were likely to have been missed.

Abstracts from retained records (or titles where abstractswere unavailable) were assessed independently by two re-viewers against a checklist based on definitions developedat the start of the review (26) to identify potentially relevantstudies for which full texts were obtained and/or additionalinformation sought where necessary (e.g., via author contact,Internet searching).

Studies selected for in-depth review, following duplicateassessment of full texts and resolution of disagreements by athird reviewer:

1. evaluated an educational, self-management, psychologi-cal/psychosocial, or multi-faceted program deemed to bea psycho-educational intervention on the basis that a majorcomponent of it:

(a) involved interaction (i.e., more than just didactic trans-fer of information) between a patient (i.e., not ahealth professional or caregiver alone) and interven-tion provider; and

(b) involved taking an educational, cognitive, behavioral,and/or social approach to improving outcomes inasthma; and/or

(c) addressed educational, cognitive, behavioral, or so-cial issues affecting asthma or its management; and/or

(d) addressed educational, cognitive, behavioral or socialissues resulting from the consequences of asthma.

2. targetted a sample or subgroup of patients with a definedform of or one or more risk factors or indicators associ-ated with severe or difficult asthma. Although potentially

relevant, studies of asthma patients argued to be at risk onthe basis of geographical location (e.g., living in an area ofhigh asthma morbidity, mortality, or social deprivation) orattendance at accident and emergency (A&E) or an emer-gency department (ED) on a single occasion were not ul-timately selected. These were deemed unlikely to haverecruited more than a minority of relevant patients. Fur-thermore, the impact of educational interventions on thelatter group is already the subject of a proposed Cochranereview (23).

3. included an independent control or comparison group re-ceiving an alternative form of care.

For the purposes of the more focussed review reported here,selected studies also:

1. targetted a sample or subgroup of adult patients or a samplein which the majority (i.e., >50%) were adults.

2. compared the intervention to usual care or a minimal (e.g.,didactic or “placebo”) intervention.

3. were published in English.4. provided sufficient detail in published sources or following

author contact on patients, intervention, and outcomes toallow in-depth review.

Study ClassificationFollowing selection, two reviewers independently classi-

fied and reached agreement regarding categorization of stud-ies according to:

1. the degree to which, on the basis of background workon definitions (26) and informed by emerging evidencefrom the review, they were judged to target severe or dif-ficult asthma, graded as “likely” (a single clear risk fac-tor/indicator or two weak risk factors/indicators only), or“definite” (two or more clear risk factors/indicators).

2. intervention type, divided into education, self-management (i.e., including formal self-monitoringand use of an action plan), psychosocial, or multi-facetedinterventions (i.e., a psycho-educational interventionincorporating a non-psycho-educational component[e.g., medical treatment] in addition to education andself-management).

3. study design, comprising randomized or non-randomizedcontrolled trials (RCTs, CCTs) and prospective or retro-spective controlled observational studies (COSs).

Data ExtractionData describing general study characteristics, patients,

interventions, methodological quality (see “quality assess-ment”), outcomes assessed, a descriptive summary and thesignificance of reported findings, and numerical outcome datawhere available in a suitable form (see “data synthesis”) wereextracted from all available information sources, includingany provided by authors (although it was not possible to con-tact authors for all missing information), and tabulated andchecked by a second reviewer. Disagreements or uncertain-ties were resolved via discussion.

Data SynthesisFindings for outcomes reported by four or more included

studies were qualitatively synthesized. Where two or more

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PSYCHO-EDUCATIONAL INTERVENTIONS FOR SEVERE ASTHMA 221

trials reported adequate data about comparable outcomes,summary relative risk ratio (RR) statistics for binary out-comes and standardized mean differences (SMD) for con-tinuous data were calculated for individual studies usingCochrane Revman software (version 4.2). If Forest plotswith 95% confidence intervals (CIs) and statistical tests sug-gested there was not significant heterogeneity between in-dividual study estimates (p > 0.05), quantitative syntheses(meta-analyses) were undertaken to calculate pooled effectsizes using a random effects model. Where there were suffi-cient data, subgroup or sensitivity analyses were planned toexplore relative effectiveness across different patient groupsand intervention types, and effects of the analysis model andsummary statistic used.

Quality AssessmentAs recommended (25), methodological characteristics re-

lated to randomization/selection of comparison group (as ap-propriate), outcome assessment, study sample and attrition,and analysis and reporting of results were assessed to explorestudy quality.

RESULTS

Extent and Selection of ResearchFigure 1 shows the research identified, screened, and

assessed for selection from initial and update searches. Anumber of studies initially considered for inclusion were ex-cluded based on the stricter criteria for the current review (ref-erences available on request). Seventeen adult studies withcontrol groups, published in English and for which adequate

FIGURE 1.—Literature identified, screened, selected, and reviewed indepth.

information was available for in-depth review, were included(27–43).

General Study Characteristics (Table 1)All but 1 of the included studies (33) were published since

1990, 8 since 2000; 7 were conducted in the USA, 4 in theUK, 3 in other European countries, and 1 each in Australia,Canada, and New Zealand. The majority (12 studies) ap-peared to be led by secondary care organisations. Most find-ings are therefore likely to be reasonably generalizable toWestern health service settings where care is guided by re-cent management guidelines.

PatientsFourteen studies explicitly recruited adults only, of which

nine had a minimum age of 18 and three of 16 years. Twodid not specify ages but included patients attending anadult clinic (42) or of working age (38). One study did notexplicitly state that adults were recruited, but the sampleappeared to be adults (33), one included small numbers ofchildren over 14 years of age (39) and one recruited patients2 years of age and above, but a majority were adults and itreported some adult subgroup analyses (31). Eleven studiesset an upper age limit, ranging from 40 to 72 years. Onestudy recruited women only (41).

Seven studies were judged to have “definitely” targetedpatients with severe or difficult asthma. These included twostudies by the same investigators (34, 35) of ethnic minor-ity patients with moderate-severe asthma who had multiplehospitalizations, emergency department attendances, or an

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TAB

LE

1.—

Gen

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stud

ych

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Con

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2001

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care

Targ

etin

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efini

teIn

clus

ion

crite

ria:

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ican

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ans

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.,19

97(3

0)U

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g:L

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up(7

2%of

orig

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sam

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0ye

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ofag

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part

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tfor

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Type

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incl

udin

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ngSe

tting

:A&

EPr

ovid

er(s

):2

nurs

esFo

rmat

:Med

ium

grou

p(5

–15

peop

le)

Stru

ctur

e:3

×1-

hour

sess

ions

(fre

quen

cyan

dto

tal

inte

rven

tion

dura

tion

nots

tate

d)T

imin

g:D

urin

gA

&E

visi

tfor

exac

erba

tion

Del

iver

ym

etho

ds/to

ols∗ :

D,S

,P,F

T,W

,A(T

otal

6)A

sthm

aco

nten

t†:8

topi

csre

late

dto

asth

ma

inge

nera

l,m

anag

emen

t,m

edic

atio

n,tr

igge

rsO

ther

cont

ent:

Smok

ing,

othe

rhe

alth

-rel

ated

beha

vior

s,at

titud

es/b

elie

fs(b

elie

fsin

self

-car

e),o

ther

psyc

holo

gica

lis

sues

(str

ess

man

agem

ent)

,soc

ialo

rfa

mily

issu

es,o

ther

(phy

sici

anco

mm

unic

atio

n,ot

her

med

icat

ion)

Add

-ons

:Ref

erra

l(to

stop

-sm

okin

gpr

ogra

ms

asre

quir

ed)

Usu

alca

reco

mpr

isin

gad

mis

sion

toan

ddi

scha

rge

from

A&

Ew

ithus

ualc

are

and

follo

w-u

p

Gar

rett

etal

.,19

94(3

1)N

ewZ

eala

ndco

mm

unity

Targ

etin

g:L

ikel

yIn

clus

ion

crite

ria:

Patie

nts

2–55

year

sof

age

(maj

ority

adul

tan

din

clud

ing

adul

tsub

grou

p)w

ithac

ute

asth

ma

diag

nose

dby

ado

ctor

whi

leat

tend

ing

the

emer

genc

yro

omw

holiv

edw

ithin

ade

fined

geog

raph

ical

area

with

high

A&

Eus

ean

dso

cial

depr

ivia

tion

and

inte

nded

tore

side

loca

llyfo

rne

xt9

mon

ths;

unde

rsto

odE

nglis

hsu

ffici

ently

and;

coul

dbe

cont

acte

dw

ithin

5da

ysof

atte

ndin

g.E

xclu

sion

s:N

one

stat

ed.

Rat

iona

lefo

rta

rget

ing:

Mor

talit

yan

dad

mis

sion

rate

sfo

ras

thm

ain

Auc

klan

dar

ehi

ghes

tam

ong

patie

nts

atte

ndin

gA

&E

from

with

inth

ege

ogra

phic

alar

eaof

high

soci

alan

dm

edic

alne

eds

targ

ette

d.T

his

area

also

has

ala

rge

imm

igra

ntpo

pula

tion

and

rate

sar

eup

tofo

urtim

eshi

gher

inPa

cific

Isla

nder

,eth

nic

min

ority

and

Mao

ripa

tient

sdu

eto

lack

ofse

lfm

anag

emen

tski

lls,s

ocia

lfac

tors

and

non-

atte

ndan

ce.

Type

:Edu

catio

nal

Des

crip

tion:

Com

mun

ityhe

alth

care

inte

rven

tion

com

pris

ing

educ

atio

n,lin

kto

GP/

refe

rral

Setti

ng:H

ome,

com

mun

ity,o

ther

(wor

kpla

ceor

asac

cord

ing

topa

tient

s’w

ishe

s)Pr

ovid

er(s

):4

Nur

ses

&co

mm

unity

heal

thw

orke

rsFo

rmat

:Ind

ivid

ual

Stru

ctur

e:N

umbe

rof

sess

ions

asne

eded

(mea

n3.

7,ra

nge

1–10

)w

ithdu

ratio

nof

sess

ions

depe

nden

ton

educ

atio

nal

need

sof

patie

nt,a

ndin

terv

entio

nco

ntin

ued

until

allt

opic

sco

vere

dT

imin

g:Fo

llow

ing

rece

ntat

tack

Del

iver

ym

etho

ds/to

ols∗ :

D,S

,W(T

otal

3)A

sthm

aco

nten

t†:1

1to

pics

rela

ted

toas

thm

ain

gene

ral,

man

agem

ent,

med

icat

ion,

trig

gers

,clin

icat

tend

ance

Oth

erco

nten

t:Sm

okin

g,at

titud

es/b

elie

fs,s

ocia

lor

fam

ilyis

sues

,eco

nom

icis

sues

(ass

essm

ento

fso

cial

,fina

ncia

l&cu

ltura

lbel

iefs

)A

dd-o

ns:R

efer

ral(

links

with

GPs

and

cont

actw

ithot

her

heal

th,m

enta

lhea

lthor

soci

alse

rvic

eag

enci

esor

supp

ort

stru

ctur

esas

appr

opri

ate)

Usu

alca

reco

mpr

isin

gus

ual

man

agem

entb

yph

ysic

ians

with

refe

rral

toho

spita

last

hma

clin

icfo

rso

me

patie

nts

Geo

rge

etal

.,19

99(3

2)U

SA Seco

ndar

yca

re

Targ

etin

g:L

ikel

yIn

clus

ion

crite

ria:

Adu

lts18

–45

year

sof

age

livin

gin

area

arou

ndho

spita

lwhi

chpr

edom

inan

tlypo

pula

ted

byA

fric

an-A

mer

ican

sw

how

ere

hosp

italiz

edfr

omE

Dw

ith(u

ncom

plic

ated

)ac

ute

exac

erba

tion

ofas

thm

a.E

xclu

sion

s:Pa

tient

sad

mitt

edto

inte

nsiv

eca

re;i

nabi

lity

tosp

eak

Eng

lish;

com

orbi

ddi

seas

e;ab

senc

eof

tele

phon

e;pr

egna

ncy.

Rat

iona

lefo

rta

rget

ing:

Dis

prop

ortio

nate

mor

bidi

tyan

dm

orta

lity

inpo

or,i

ndig

ent,

inne

r-ci

typa

tient

sdu

eto

alle

rgen

s,sm

okin

gan

dps

ycho

soci

alfa

ctor

s.

Type

:Mul

ti-fa

cete

dD

escr

iptio

n:C

ompr

ehen

sive

inpa

tient

prog

ram

incl

udin

ged

ucat

ion,

self

-man

agem

ent,

addr

essi

ngso

cioe

cono

mic

barr

iers

via

soci

alw

orke

ran

dw

ithad

ditio

nalf

ollo

w-u

pSe

tting

:Inp

atie

nt,o

utpa

tient

Prov

ider

(s):

Ast

hma

clin

ical

nurs

esp

ecia

list

Form

at:I

ndiv

idua

lSt

ruct

ure:

Num

ber,

freq

uenc

y,an

ddu

ratio

nof

sess

ions

not

stat

ed.T

otal

dura

tion

ofin

terv

entio

nde

pend

ento

nle

ngth

ofst

ay(m

ean

2.1

days

)w

ithou

tpat

ient

follo

w-u

p7

days

afte

rdi

scha

rge

Tim

ing:

Beg

undu

ring

adm

issi

onfo

rex

acer

batio

nD

eliv

ery

met

hods

/tool

s∗ :L

,D,S

,T(t

otal

4)A

sthm

aco

nten

t†:1

0to

pics

rela

ted

toas

thm

ain

gene

ral,

man

agem

ent,

med

icat

ion,

clin

icat

tend

ance

Oth

erco

nten

t:O

ther

psyc

holo

gica

liss

ues,

soci

al,o

rfa

mily

issu

es,e

cono

mic

issu

es(s

cree

ned

for

obst

acle

sto

care

incl

udin

gin

abili

tyto

fillp

resc

ript

ions

,lac

kof

tran

spor

tatio

n,la

ckof

child

care

,sub

stan

ceab

use

whi

chad

dres

sed

with

soci

alw

orke

r)A

dd-o

ns:M

edic

altr

eatm

ent(

use

ofbe

dsid

esp

irom

etry

,di

scha

rge

plan

ning

and

outp

atie

ntfo

llow

-up

whi

chw

ere

not

prov

ided

aspa

rtof

usua

lcar

e),R

efer

ral(

liais

onw

ithso

cial

wor

kers

asne

eded

)

Usu

alca

reco

mpr

isin

gin

patie

nttr

eatm

enti

nclu

ding

nebu

lized

albu

tero

land

intr

aven

ous

met

hylp

redn

isol

one

sodi

um;

educ

atio

n,pe

akflo

wm

easu

rem

ent

asne

eded

. (Con

tinu

edon

next

page

)

223

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

ichi

gan

Uni

vers

ity o

n 10

/31/

14Fo

r pe

rson

al u

se o

nly.

TAB

LE

1.—

Gen

eral

stud

ych

arac

teri

stic

san

dde

tails

ofpa

tient

s,in

terv

entio

nsan

dco

ntro

lgro

ups.

(Con

tinu

ed)

Stud

yC

ount

ry&

setti

ngTa

rget

ing

ofse

vere

/dif

ficul

tas

thm

aan

dsa

mpl

ese

lect

ion

Inte

rven

tion

Con

trol

grou

p(s

)

Gro

en&

Pels

er19

60(3

3)T

he Net

herl

ands

Setti

ngun

clea

r

Targ

etin

g:D

efini

teIn

clus

ion

crite

ria:

App

ear

tobe

adul

ts(a

lthou

ghno

texp

licitl

yst

ated

)ho

spita

lized

atle

asto

nce

for

seve

rest

atus

asth

mat

icus

,mos

twith

man

yho

spita

lizat

ions

and

very

seve

reas

thm

a.E

xclu

sion

s:N

one

stat

ed.

Rat

iona

lefo

rtar

getin

g:N

oex

plic

itdi

scus

sion

ofat

-ris

kst

atus

.

Type

:Psy

chos

ocia

lD

escr

iptio

n:Ps

ycho

ther

apy

Setti

ng:N

otst

ated

Prov

ider

(s):

2ph

ysic

ians

with

nosp

ecifi

ctr

aini

ngin

psyc

hiat

rybu

texp

erie

nce

with

indi

vidu

alps

ycho

-the

rape

utic

tech

niqu

es;s

uppo

rtfr

omps

ychi

atri

st,

psyc

hoso

mat

icre

sear

cher

sFo

rmat

:Gro

up(s

ize

nots

tate

d)St

ruct

ure:

Twic

ew

eekl

yse

ssio

nspl

anne

das

1ho

ur,a

ctua

llyup

to75

min

s,pr

ovid

edov

erse

vera

lyea

rsT

imin

g:N

osp

ecifi

ctim

ing

toas

thm

aep

isod

eD

eliv

ery

met

hods

/tool

s*:D

,R,F

T(T

otal

3)A

sthm

aco

nten

t†:1

topi

cre

late

dto

med

icat

ion

Oth

erco

nten

t:O

ther

psyc

holo

gica

liss

ues,

soci

alor

fam

ilyis

sues

(litt

lede

tail

prov

ided

)A

dd-o

ns:N

one

1.E

nhan

ced

med

ical

care

com

pris

ing

patie

nts

trea

ted

with

sym

ptom

atic

ther

apy

and,

from

3m

onth

sto

4ye

ars,

prev

entiv

eth

erap

y.2.

Usu

alca

reco

mpr

isin

gpa

tient

str

eate

dw

ithsy

mpt

omat

icth

erap

yon

ly

Kel

soet

al.,

1995

(34)

USA Se

cond

ary

care

Targ

etin

g:D

efini

teIn

clus

ion

crite

ria:

Afr

ican

-Am

eric

ans

18+

year

sof

age

with

adi

agno

sis

ofm

oder

ate-

seve

reas

thm

a(a

spe

rA

mer

ican

Tho

raci

cSo

ciet

ycr

iteri

a)ad

mitt

edto

ED

with

acut

eas

thm

a,w

hoha

d5+

ED

visi

tsin

the

last

2ye

ars,

3+E

Dvi

sits

inth

ela

stye

ar,2

+ho

spita

lizat

ions

inth

ela

st2

year

sO

Ran

inte

nsiv

eca

read

mis

sion

inth

ela

st2

year

s.E

xclu

sion

s:Pa

tient

sw

ithch

roni

cbr

onch

itis,

emph

ysem

a,ot

her

chro

nic

pulm

onar

ydi

seas

e,si

gnifi

cant

card

iac

dise

ase,

psyc

hosi

sor

subs

tanc

eab

use,

who

wer

epr

egna

ntor

unab

leto

use

ape

akflo

wm

eter

orm

eter

eddo

sein

hale

rw

ithsp

acer

corr

ectly

.R

atio

nale

for

targ

etin

g:A

fric

an-A

mer

ican

sha

veth

ree

times

the

mor

talit

yra

tefo

ras

thm

a,si

mila

rto

othe

ret

hnic

min

oriti

es,a

ndus

eth

eE

Das

thei

rm

ain

sour

ceof

care

.

Type

:Mul

ti-fa

cete

dD

escr

iptio

n:E

duca

tion

and

long

-ter

mth

erap

eutic

inte

rven

tion

incl

udin

ged

ucat

ion,

self

-man

agem

ent,

med

ical

trea

tmen

tSe

tting

:A&

E,o

utpa

tient

Prov

ider

(s):

Stud

yin

vest

igat

ors

Form

at:I

ndiv

idua

lSt

ruct

ure:

1×

1-ho

urse

ssio

ndu

ring

aver

age

4.4-

hour

stay

inE

Dw

ithfo

llow

-up

atcl

inic

afte

r1

wee

kth

enev

ery

2w

eeks

to6

mon

ths

for

1ye

arT

imin

g:Im

med

iate

lyfo

llow

ing

emer

genc

yde

part

men

ttr

eatm

ent

Del

iver

ym

etho

ds/to

ols∗ :

L,D

,S,T

,W(T

otal

5)A

sthm

aco

nten

t†:1

2to

pics

rela

ted

toas

thm

ain

gene

ral,

man

agem

ent,

med

icat

ion,

trig

gers

,clin

icat

tend

ance

Oth

erco

nten

t:O

ther

heal

th-r

elat

edbe

havi

ors

Add

-ons

:Med

ical

trea

tmen

t(pr

escr

iptio

nsfo

rin

hale

dst

eroi

ds,b

eta-

agon

ists

,em

erge

ncy

pred

niso

lone

and

othe

rm

edic

atio

nsas

nece

ssar

y).

Usu

alca

reco

mpr

isin

gpa

tient

sm

eetin

gsa

me

incl

usio

ncr

iteri

aad

mitt

edor

trea

ted

inE

Ddu

ring

sam

etim

epe

riod

asin

terv

entio

ngr

oup

inot

her

loca

lhos

pita

ls.

Kel

soet

al.,

1996

(35)

USA Se

cond

ary

care

Targ

etin

g:D

efini

teIn

clus

ion

crite

ria:

Afr

ican

-Am

eric

ans

(but

note

xplic

itly

stat

edin

incl

usio

ncr

iteri

a)ag

ed18

+ye

ars

ofag

em

eetin

gU

SN

atio

nalA

sthm

aE

duca

tion

&Pr

even

tion

Prog

ram

crite

ria

for

mod

erat

e-se

vere

asth

ma

and

with

5+E

Dvi

sits

inla

st2

year

s,3+

ED

visi

tsin

last

year

,2+

hosp

italiz

atio

nsin

last

2ye

ars

OR

anin

tens

ive

care

adm

issi

onin

last

2ye

ars.

Exc

lusi

ons:

CO

PD;c

linic

ally

sign

ifica

ntca

rdia

cdi

seas

e;ps

ycho

sis,

subs

tanc

eab

use;

preg

nanc

y;in

abili

tyto

use

peak

flow

met

eror

inha

ler

with

spac

erco

rrec

tly.

Rat

iona

le:A

sthm

am

orbi

dity

and

mor

talit

yhi

gher

inA

fric

an-A

mer

ican

s.

Type

:Mul

ti-fa

cete

dD

escr

iptio

n:E

duca

tiona

lint

erve

ntio

nw

ithlo

ng-t

erm

man

agem

entp

rogr

amm

ein

clud

ing

educ

atio

n,se

lf-m

anag

emen

t,m

edic

altr

eatm

ent

Setti

ng:O

utpa

tient

Prov

ider

(s):

Doc

tor,

phar

mac

ist

Form

at:I

ndiv

idua

lSt

ruct

ure:

1×

1-ho

urin

itial

visi

tfol

low

edby

unst

ated

num

ber

offo

llow

-up

cont

acts

prov

ided

mon

thly

initi

ally

,th

en2–

3m

onth

lyth

erea

fter

base

don

need

(tot

alin

terv

entio

ndu

ratio

nno

tsta

ted)

Tim

ing:

Non

eD

eliv

ery

met

hods

/tool

s∗ :D

,S,T

,W(T

otal

4)A

sthm

aco

nten

t†:1

4to

pics

rela

ted

toas

thm

ain

gene

ral,

man

agem

ent,

med

icat

ion,

trig

gers

,clin

icat

tend

ance

Oth

erco

nten

t:A

ttitu

des/

belie

fsA

dd-o

ns:M

edic

altr

eatm

ent(

optim

izat

ion

ofth

erap

yan

dlin

king

this

tous

eof

ase

lf-m

anag

emen

tpla

n).

Usu

alca

reco

mpr

isin

gre

tros

pect

ive

grou

pof

patie

nts,

14ou

tof

18of

who

msa

wpr

imar

yca

reph

ysic

ian,

4of

who

msa

wa

pulm

onol

ogis

t/al

lerg

ist.

Freq

uenc

yof

offic

evi

sits

for

cont

rolp

atie

nts

coul

dno

tbe

dete

rmin

ed.

224

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

ichi

gan

Uni

vers

ity o

n 10

/31/

14Fo

r pe

rson

al u

se o

nly.

May

oet

al.,

1990

(36)

USA Se

cond

ary

care

Targ

etin

g:D

efini

teIn

clus

ion

crite

ria:

Adu

lts18

+ye

ars

ofag

ew

itha

prim

ary

diag

nosi

sof

acut

eas

thm

aex

acer

batio

nas

per

Am

eric

anT

hora

cic

Soci

ety

defin

ition

and

>4

ER

visi

tsin

last

12m

onth

sor

>1

hosp

italiz

atio

nin

last

24m

onth

s.E

xclu

sion

s:M

ildas

thm

a;re

mot

ere

side

nce

orin

pris

on,d

eaf

mut

e;in

trav

enou

sdr

ugab

user

s;ov

ertc

entr

alne

rvou

ssy

stem

/men

tali

llnes

s;se

vere

alco

holis

m;p

riva

tefo

llow

-up;

disc

harg

edbe

fore

eval

uatio

nin

hosp

ital.

Rat

iona

lefo

rta

rget

ing:

Loc

alar

ea(L

ower

Eas

tSid

eof

New

Yor

k)de

nsel

ypo

pula

ted,

soci

oeco

nom

ical

lyde

pres

sed,

whe

reas

thm

aco

mm

onca

use

for

adm

issi

on(6

70/y

ear)

and

cert

ain

patie

nts,

labe

led

as“d

iffic

ult”

have

freq

uent

adm

issi

ons.

Type

:Mul

ti-fa

cete

dD

escr

iptio

n:Sp

ecia

listc

linic

prog

ram

com

pris

ing

educ

atio

n,se

lf-m

anag

emen

t,op

en-d

oor

polic

y,m

edic

altr

eatm

ent

Setti

ng:O

utpa

tient

Prov

ider

(s):

1R

espi

rato

rynu

rse

spec

ialis

t,1

resp

irat

ory

doct

orFo

rmat

:Ind

ivid

ual

Stru

ctur

e:In

itial

sess

ion

of>

1ho

ur,f

ollo

wed

byfu

rthe

r>

30m

inse

ssio

nsas

need

ed,r

angi

ngfr

omon

cea

wee

kto

1ev

ery

6m

onth

spl

usph

one

cont

actb

etw

een

for

am

axim

umpe

riod

of8

mon

ths

Tim

ing:

Patie

nts

recr

uite

dfo

llow

ing

adm

issi

on,u

ncle

arho

wlo

ngaf

ter

inte

rven

tion

bega

nD

eliv

ery

met

hods

/tool

s∗ :D

,S,T

(Tot

al3)

Ast

hma

cont

ent†

:8to

pics

rela

ted

toas

thm

ain

gene

ral,

man

agem

ent,

med

icat

ion,

clin

icat

tend

ance

Oth

erco

nten

t:N

one

stat

edA

dd-o

ns:M

edic

altr

eatm

ent(

redu

ctio

nin

orm

inim

alus

eof

med

icat

ions

requ

ired

toco

ntro

lsym

ptom

s)

Usu

alca

reco

mpr

isin

gre

gula

rou

tpat

ient

care

inch

esto

rm

edic

alcl

inic

atlo

calh

ospi

tal,

neig

hbor

hood

clin

ics,

orlo

cal

phys

icia

ns.

Mor

ice

&W

renc

h20

01(3

7)

UK

Seco

ndar

yca

reTa

rget

ing:

Lik

ely

Incl

usio

ncr

iteri

a:Pa

tient

s16

–72

year

sof

age

hosp

italiz

edw

itha

prim

ary

diag

nosi

sof

acut

eas

thm

a.E

xclu

sion

s:U

nabl

eor

unw

illin

gto

com

plet

efo

llow

-up

ques

tionn

aire

s;un

derl

ying

CO

PD;p

revi

ous

part

icip

atio

nin

aned

ucat

iona

lpro

gram

from

aho

spita

l-ba

sed

asth

ma

nurs

e.R

atio

nale

for

targ

etin

g:In

adeq

uate

self

-man

agem

ent

cont

ribu

tes

tom

orta

lity

and

mor

bidi

ty.W

ritte

nm

anag

emen

tpl

ans

are

apo

stiv

est

epbu

tthe

irus

eful

ness

isde

pend

ento

nid

entif

ying

and

targ

ettin

gth

ose

asth

mat

ics

mos

tatr

isk.

Type

:Sel

f-m

anag

emen

tD

escr

iptio

n:E

duca

tion

prog

ram

incl

udin

gse

lf-m

anag

emen

tSe

tting

:Inp

atie

ntPr

ovid

er(s

):1

asth

ma

nurs

eFo

rmat

:Ind

ivid

ual

Stru

ctur

e:M

inim

umof

2se

ssio

ns,a

vera

ge30

-min

sdu

ratio

n,de

liver

edon

cons

ecut

ive

days

,plu

son

ebe

fore

disc

harg

ew

here

poss

ible

,with

tota

ldur

atio

nof

inte

rven

tion

bein

g2+

days

,dep

ende

nton

leng

thof

adm

issi

onT

imin

g:In

itial

asse

ssm

entw

ithin

48ho

urs

ofad

mis

sion

Del

iver

ym

etho

ds/to

ols∗ :

L,D

,S,W

(Tot

al4)

Ast

hma

cont

ent†

:11

topi

csre

late

dto

asth

ma

inge

nera

l,m

anag

emen

t,m

edic

atio

n,tr

igge

rsO

ther

cont

ent:

Oth

erps

ycho

logi

cali

ssue

s(f

ears

&an

xiet

ies

rela

ted

toho

me

man

agem

ent)

,soc

ialo

rfa

mily

issu

es(r

elat

ives

invo

lved

atpa

tient

’sre

ques

t),o

ther

(infl

uenc

eof

lifes

tyle

activ

ities

,e.g

.,le

isur

e&

occu

patio

n)A

dd-o

ns:N

one

Usu

alca

reco

mpr

isin

gro

utin

eca

refr

omm

edic

alan

dnu

rsin

gst

aff

Nat

hell,

2005

(38)

Swed

enTe

rtia

ryca

reTa

rget

ing:

Lik

ely

Incl

usio

ncr

iteri

a:A

dults

born

afte

r19

41(i

.e.,

age

<55

year

sat

time

ofid

entifi

catio

n)in

aco

mpu

lsor

ysi

ckle

ave

sche

me

prim

arily

for

man

ualw

orke

rsw

hoha

dbe

enon

sick

leav

efr

ompr

ivat

ese

ctor

wor

kfo

rm

ore

than

2w

eeks

in2

year

sdu

eto

resp

irat

ory

sym

ptom

san

din

who

ma

diag

nosi

sof

asth

ma

was

mad

eas

per

Am

eric

anT

hora

cic

Soci

ety

crite

ria

via

inte

rvie

wan

dcl

inic

alex

amin

atio

n.E

xclu

sion

s:N

one

stat

ed.

Rat

iona

lefo

rta

rget

ing:

Maj

orpr

opor

tion

ofth

eco

sts

ofas

thm

aat

trib

utab

leto

prod

uctiv

itylo

sses

and

soci

etal

cost

sin

rela

tion

tosi

ckle

ave

com

pens

atio

n,th

eref

ore

impo

rtan

tto

redu

cesi

ckle

ave

for

asth

ma.

Type

:Mul

ti-fa

cete

dD

escr

iptio

n:R

ehab

ilita

tion

prog

ram

me

com

pris

ing

educ

atio

n,se

lf-m

anag

emen

t,op

timiz

atio

nof

med

icat

ions

,phy

sica

ltr

aini

ng,a

ndco

ping

skill

sac

quis

ition

Setti

ng:I

npat

ient

Prov

ider

(s):

Phys

icia

n,nu

rse,

phys

ioth

erap

ist,

psyc

holo

gist

,di

etic

ian,

voca

tiona

lthe

rapi

st,l

abte

chni

cian

Form

at:N

otst

ated

Stru

ctur

e:4

wee

kpr

ogra

m(n

umbe

r,fr

eque

ncy

&du

ratio

nof

cont

acts

nots

tate

d)pl

usfo

llow

-up

bypo

st/e

-mai

l/pho

nefo

ron

eye

arT

imin

g:N

osp

ecifi

ctim

ing

toas

thm

aep

isod

eD

eliv

ery

met

hods

/tool

s∗ :L

,D,S

,T,W

(Tot

al5)

Ast

hma

cont

ent†

:6to

pics

rela

ted

toas

thm

ain

gene

ral,

man

agem

ent,

med

icat

ion,

trig

gers

Oth

erco

nten

t:O

ther

heal

th-r

elat

edbe

havi

or(w

eigh

tre

duct

ion

orm

aint

enan

ce),

othe

rps

ycho

logi

cali

ssue

s(c

opin

gw

ithas

thm

a,tr

eatm

enta

ndco

nseq

uenc

es)

Add

-ons

:Med

ical

care

(opt

imiz

atio

nof

drug

ther

apy)

,ex

erci

se(p

erso

nalp

hysi

calt

rain

ing

prog

ram

)

Usu

alca

rein

whi

chpa

tient

sad

vise

dto

see

thei

rre

gula

rdo

ctor

asus

ual

(Con

tinu

edon

next

page

)

225

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

ichi

gan

Uni

vers

ity o

n 10

/31/

14Fo

r pe

rson

al u

se o

nly.

TAB

LE

1.—

Gen

eral

stud

ych

arac

teri

stic

san

dde

tails

ofpa

tient

s,in

terv

entio

nsan

dco

ntro

lgro

ups.

Stud

yC

ount

ry&

setti

ngTa

rget

ing

ofse

vere

/dif

ficul

tas

thm

aan

dsa

mpl

ese

lect

ion

Inte

rven

tion

Con

trol

grou

p(s

)

Osm

anet

al.,

2002

(39)

UK

Seco

ndar

yca

reTa

rget

ing:

Lik

ely

Incl

usio

ncr

iteri

a:Pa

tient

s14

–60

year

sof

age

with

aco

nfirm

eddi

agno

sis

and

hosp

italiz

edw

ithac

ute

asth

ma.

Exc

lusi

ons:

Non

est

ated

.R

atio

nale

for

targ

etin

g:A

fter

acut

eas

thm

aad

mis

sion

sth

ere

isa

high

rate

ofre

adm

issi

onw

ith1

in5

patie

nts

bein

gre

adm

itted

.

Type

:Sel

f-m

anag

emen

tD

escr

iptio

n:Se

lf-m

anag

emen

tedu

catio

npr

ogra

mSe

tting

:Inp

atie

ntPr

ovid

er(s

):1

Res

pira

tory

nurs

eFo

rmat

:Ind

ivid

ual

Stru

ctur

e:2

×30

min

sess

ions

(fre

quen

cyan

dto

tal

inte

rven

tion

dura

tion

nots

tate

d)T

imin

g:Fo

llow

ing

adm

issi

onD

eliv

ery

met

hods

/tool

s∗ :D

,S,W

(Tot

al3)

Ast

hma

cont

ent†

:11

topi

csre

late

dto

asth

ma

inge

nera

l,m

anag

emen

t,m

edic

atio

n,tr

igge

rsO

ther

cont

ent:

Non

est

ated

Add

-ons

:Non

e

Usu

alca

reco

mpr

isin

gst

anda

rdca

reby

mor

eth

an40

gene

ralm

edic

alan

dre

spir

ator

yph

ysic

ians

,usu

ally

incl

udin

gfo

llow

-up

inan

outp

atie

ntcl

inic

atdi

scre

tion

ofph

ysic

ian

aspe

rB

ritis

hT

hora

cic

Soci

ety

guid

elin

esan

dlo

cal

prac

tice.

Cou

ldin

clud

eed

ucat

ion

orus

eof

man

agem

entp

lans

.

Pute

tal.,

2003

(40)

Bel

gium

Seco

ndar

yca

re

Targ

etin

g:L

ikel

yIn

clus

ion

crite

ria:

Adu

lts18

–65

year

sof

age

with

adi

agno

sis

ofas

thm

aac

cord

ing

toA

mer

ican

Tho

raci

cSo

ciet

ycr

iteri

a,an

dsy

mpt

oms

duri

ngth

ela

st6

mon

ths

(sta

ted

that

thos

ere

port

ing

sym

ptom

olog

yan

dim

pair

men

tdes

pite

adeq

uate

med

ical

trea

tmen

ttar

gete

dbu

tunc

lear

from

crite

ria

how

this

was

done

).E

xclu

sion

s:O

ccup

atio

nala

sthm

a,ni

cotin

e,dr

ugor

alco

hol

abus

e,br

ittle

asth

ma,

prev

ious

part

icip

atio

nin

aned

ucat

iona

lor

othe

ras

thm

apr

ogra

mm

e.R

atio

nale

for

targ

etin

g:Pa

tient

sre

port

ing

sym

ptom

olog

yan

dim

pair

men

tdes

pite

adeq

uate

med

ical

trea

tmen

trep

rese

nta

chal

leng

ein

clin

ical

prac

tice

and

caus

efr

ustr

atio

nto

clin

icia

ns

Type

:Psy

chos

ocia

lD

escr

iptio

n:E

duca

tion

and

cogn

itive

-beh

avio

rali

nter

vent

ion

Setti

ng:O

utpa

tient

Prov

ider

(s):

2re

sear

cher

sFo

rmat

:Ind

ivid

ual

Stru

ctur

e:6

×1-

hour

sess

ions

(fre

quen

cyan

dto

tal

inte

rven

tion

dura

tion

nots

tate

d)T

imin

g:N

osp

ecifi

ctim

ing

toas

thm

aep

isod

eD

eliv

ery

met

hods

/tool

s∗ :D

,S,F

T,W

(Tot

al4)

Ast

hma

cont

ent†

:5to

pics

rela

ted

toas

thm

ain

gene

ral,

man

agem

ent,

med

icat

ion,

trig

gers

.O

ther

cont

ent:

Atti

tude

s/be

liefs

(neg

ativ

ean

dir

ratio

nali

llnes

san

dm

edic

atio

npe

rcep

tions

and

belie

fs),

othe

rps

ycho

logi

cali

ssue

s(p

robl

emar

eas

asin

dica

ted,

e.g.

,an

xiet

y)A

dd-o

ns:N

one

Usu

alca

reco

mpr

isin

gw

aitin

glis

tco

ntro

lgro

up(n

ode

scri

ptio

ngi

ven)

Ros

set

al.,

2005

(41)

Can

ada

Res

earc

hfa

cilit

y

Targ

etin

g:L

ikel

yIn

clus

ion

crite

ria:

Wom

en(d

ueto

high

erra

tes

ofpa

nic

diso

rder

)18

–65

year

sof

age

with

aph

ysic

ian

diag

nosi

sof

asth

ma

who

had

been

refe

rred

toa

pulm

onar

ysp

ecia

listo

rat

tend

edth

eE

Dfo

ran

acut

eas

thm

aep

isod

eA

ND

wer

eid

entifi

edas

havi

nga

prim

ary

diag

nosi

sof

pani

cdi

sord

er(w

ithno

,mild

,or

mod

erat

eag

roph

obic

avoi

danc

ean

dat

leas

t3pa

nic

atta

cks

inth

ela

st3

wee

ks)

follo

win

ga

DSM

-IV

stru

ctur

eddi

agno

ticin

terv

iew

and

expe

rtdi

scus

sion

.E

xclu

sion

s:R

ecen

tcha

nge

inps

ycho

trop

hic

med

icat

ion

ordo

se,o

ther

med

ical

cond

ition

cont

rain

dica

ting

part

icip

atio

n(e

.g.,

emph

ysem

a,or

gani

cbr

ain

synd

rom

e),b

ipol

ardi

sord

er,s

chiz

ophr

enia

,obs

essi

ve-c

ompu

lsiv

edi

sord

er,

alco

holo

rdr

ugde

pend

ence

.R

atio

nale

for

targ

etin

g:H

ighe

rth

anno

rmal

rate

sof

pani

cdi

sord

erin

asth

ma

patie

nts.

Com

bina

tion

ofpa

nic

and

asth

ma

atta

cks

lead

sto

men

tal,

emot

iona

l,an

dph

ysic

alan

guis

h,in

crea

sed

heal

thse

rvic

eus

e,an

din

crea

sed

asth

ma

mor

bidi

tyan

dm

orta

lity.

Type

:Psy

chos

ocia

lD

escr

iptio

n:C

ogni

tive-

beha

vior

altr

eatm

enta

ndas

thm

aed

ucat

ion

prog

ram

incl

udin

gse

lf-m

anag

men

ent

Setti

ng:N

otst

ated

Prov

ider

(s):

2nu

rse

clin

icia

ns(o

netr

aine

din

asth

ma,

one

inps

ychi

atry

)Fo

rmat

:Sm

allg

roup

(<5

peop

le)

Stru

ctur

e:12

×90

min

sess

ions

,8co

nduc

ted

twic

ew

eekl

yfo

r4

wee

ks,4

cond

ucte

dw

eekl

yfo

r4

wee

ksm

akin

g8-

wee

kin

terv

entio

nin

tota

l.T

imin

g:N

osp

ecifi

ctim

ing

toas

thm

aep

isod

eD

eliv

ery

met

hods

/tool

s∗ :L

,D,S

,FT,

W(t

otal

5)A

sthm

aco

nten

t†:1

0to

pics

rela

ted

toas

thm

ain

gene

ral,

man

agem

ent,

med

icat

ion,

trig

gers

Oth

erco

nten

t:A

ttitu

des/

belie

fs(a

ddre

ssin

gfa

ulty

cogn

itive

appr

aisa

lsco

ntri

butin

gto

anxi

ety

and

pani

c),o

ther

psyc

holo

gica

liss

ues

(gen

eral

info

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227

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al u

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intensive care admission, and a study of primarily low-income, ethnic minority patients, again with multiple hos-pitalizations or emergency attendances, referred to as having“difficult” asthma (36). Four further studies (27, 29, 33, 42)identified patients on the basis of a clear indicator of severeor poorly controlled asthma (e.g., diagnosis of severe asthma,hospitalization, multiple emergency attendances) in combi-nation with other sociodemographic (e.g., ethnic minority),behavioral (e.g., poor compliance), or clinical (e.g., previoushospitalization or emergency attendances) risk factors, withmost referring to patients as being “high risk.”

Of the remaining 10 studies, judged “likely” to have tar-geted severe or difficult asthma, 4 recruited hospitalized pa-tients (28, 37, 39, 43), one of which (39) included a sub-group analysis of patients with previous admissions, judgedto be at higher risk. Three studies (30–32) targeted patientson the basis of a relatively weak indicator of severity/poorcontrol (emergency attendance with or without hospitaliza-tion) in combination with social deprivation or ethnic minor-ity status. This was identified in two cases on the basis ofgeographical location alone (31, 32) and in one on the ba-sis of reporting a subgroup analysis from an RCT targeting abroader patient group that had been excluded from this reviewin its own right (30). The remaining studies selected asthmapatients with high anxiety/panic (41), taking sick leave dueto asthma (38), and with persistent symptoms despite ade-quate treatment (40). It was not clear how the latter wereidentified.

All studies were judged to provide a clear description ofthe target population, usually justified on the basis of in-creased risk of mortality, morbidity, or service use. How-ever, two studies did not make explicit reference to patientsbeing “at risk” (33, 43), and 10 specified criteria relatedto disease severity or the presence of physical, psychoso-cial, or behavioral co-morbidities that would have excludedsome of the most at-risk patients (29, 30, 32, 34–37, 40, 41,43).

InterventionsAll studies evaluated a single psycho-educational program

of which three were classified as educational (28, 30, 31), fouras self-management (27, 37, 39, 43), three as psychosocial(33, 40, 41), and seven as multi-faceted (29, 32, 34–36, 38,42). Details of individual interventions are provided in Table1 and an overview is provided in Box 1.

ComparisonsAll studies included a comparison group receiving usual

care, of which 14 gave at least some description. In all butone study from 1960 (33), the usual care appears similarto current recommended management. However, referencingof guidelines as the basis for this was variable even in therecent studies and in five identification of inadequacies inmedical care in light of guidelines either generally (e.g., lackof routine education), or for the particular patients targeted(e.g., under-use of preventive medication for ethnic minor-ity patients), provided a rationale for implementation of theintervention (34, 35, 37, 39, 43). Three further studies iden-tified inadequacies in standard care as a result of providingtheir intervention (31, 41, 42).

Study Quality (Table 2)Randomization/Selection of Control Subjects. There

were 13 trials, all RCTs, in which the unit of randomizationwas the patient. Only 6 described randomization methods (32,36, 38–40, 42), of which 5 were considered adequate (32, 38–40, 42). Four referred to concealed allocation (29, 38–40).

One study (28) described as randomized was classified asa COS since intervention patients comprised those admittedto the study hospital and controls comprised those admittedto other local hospitals, all of whom appeared to be identi-fied prospectively. In two other COSs (34, 35), interventionpatients received follow-up prospectively but a naturally oc-curring control group, comprising patients meeting criteriabut treated elsewhere in the district, were identified retro-spectively. In the final COS (33), intervention and controlpatients appeared to be identified retrospectively from thesame site over a similar timeframe.

Outcome Assessment. Six RCTs (27, 30, 31, 39, 40, 43)and one COS (28) made reference to blinding those involvedin assessing or scoring outcomes. In only five RCTs (29, 30,36, 39, 42) and one COS (33) was there clearly both a singleprimary outcome and endpoint. In five further RCTs and twoCOSs either a single primary outcome (38) or endpoint (27,28, 31, 32, 34, 43) was apparent.

Sample and Attrition. Sample sizes ranged from 25 (40)to 500 patients (31), with a median of 86. The largest studyconducted some subgroup analyses of children and adultsconsidered separately here.

All but one RCT (40) was judged to have provided clearselection criteria. Only five RCTs reported sample size esti-mates (27, 30, 31, 39, 42), but several appeared to fail to meetthese. The proportion of patients approached who agreed toparticipate ranged from 41% (43) to 100% (29, 36), with amedian of 65%, in the 12 RCTs for which this could be as-certained. In three (31, 42, 43) of the six RCTs (30, 31, 38,41–43) that assessed the comparability of non-participants,there was some evidence of differences, suggesting difficul-ties in recruiting patients truly representative of the targetpopulation.

All RCTs and all but one of the COSs (28) presented dataon, or reported assessment of, group comparability at base-line. In five RCTs (27, 29, 37,40, 41), minor differences werejudged unlikely to have any major impact on results but twoRCTs (39, 42) and two COSs (33, 34) examined effects ofvarious group differences using adjusted analyses.

Numbers for whom follow-up data were available couldnot be ascertained for two COSs (34, 35). Within other stud-ies, follow-up rates often varied for different outcomes atdifferent time points. An assessment of the minimum follow-up reported ranged from 39% (40) to 100% (30, 36), with amedian of 75%. Only five studies (30, 31, 33, 36, 38, 39) re-ported less than 15% loss to follow-up, sometimes considereda maximum acceptable to prevent attrition bias. However, inthe three RCTs that reported assessment of the comparabilityof withdrawals, no clear differences were found (31, 41, 42).

Analysis and Reporting. Details of analyses were re-ported or could be ascertained for all RCTs but for only 2of the COSs (33, 35). Six RCTs (29–32, 38, 42) specified

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BOX 1.—Overview of intervention characteristics.

SettingAll but two studies, both of psychosocial interventions (33, 41), indicated the setting for intervention delivery. Seven, including all but one self-management

intervention, were delivered at least partly in an inpatient setting (27–29, 32, 37–39), four solely on an outpatient basis (35, 36, 40, 43), two in the emergencydepartment (30, 34), and two in community or home environments (31, 42).

ProvidersTwelve studies involved nurses and five doctors, all but one of which evaluated a multi-faceted intervention incorporating additional medical treatment. One

educational (31), one psychosocial (33), and four multi-faceted interventions (35, 36, 38, 42) involved additional professionals (e.g., psychologists, communityhealth workers, pharmacists, physiotherapists, dieticians). In three studies (34, 40, 43) the providers’ professions were unclear. Eleven studies reported on thenumber of providers (27, 29, 30, 31, 33, 36, 37, 39–42), ranging from one to four. Six referred to specific training undertaken by, or supervision given to,providers (28, 30, 31, 33, 39, 42). Four studies included details of providers’ experience, gender or shared ethnic, linguistic or cultural background withpatients (31, 33, 41, 42).

Format, structure and timingAll but one study (38) provided information on the delivery format. In 12, delivery was on an individual basis, 2 delivered interventions to medium-sized groups

(30, 43), 1 to a small group (41), and 1 to a group of unspecified size (33). Only 7 studies provided complete information on the number, duration, andfrequency of intervention contacts and total intervention duration (31, 34, 36, 37, 41–43). Across all studies where one or more of these dimensions wasreported, they often varied according to patient needs, time available for contact (e.g., during an admission), or at different stages of the intervention, but wherespecific figures could be ascertained:

• the number of sessions varied from one, for a self-management intervention (43), to 12, for a psychosocial intervention (41);• individual session duration varied from a minimum of 30 minutes, for one educational (28) and two self-management interventions (37, 39), to up to three

hours, for a self-management intervention (43), with sessions most commonly lasting around an hour;• the frequency of contacts ranged from daily, in one self-management program (37), to initial contacts at monthly intervals in a multi-faceted intervention (35);• the intervention duration ranged from the time taken to deliver a single session in one self-management program (43) to several years in a psychosocial

intervention (33); and• total contact time ranged from a minimum of 30 minutes during a single educational session (28) to 9 hours for a psychosocial intervention (41).• judgments about the overall intensity of the intervention could only be made for a small number of studies but appeared greatest for psychosocial and

multi-faceted interventions.Eleven interventions, including all the educational and self-management programs and half the multi-faceted programs, followed an asthma episode (e.g.,

hospitalization, emergency attendance, recent attack) (27–32, 34, 36, 37, 39, 43), but the exact timing of the start of the intervention from the episode was notalways clear.

Delivery methods/toolsAll interventions appeared to use formal or informal discussion and/or questioning in groups or individually, commonly covering experiences with, and problems

related to, asthma management. All but one study of a psychosocial intervention (33) incorporated skills training, including demonstration of correct use ofinhalers, related equipment and peak flow meters, and training in self-management procedures, relaxation or other psychotherapeutic techniques, triggermanagement or social skills. Fourteen studies supplemented face-to-face delivery with written information and 7 with telephone contact. Seven interventionsincluded a didactic component. All 3 psychosocial interventions made use of formal psychotherapeutic techniques, 2 cognitive-behavioral principles (40, 41),in delivery. One educational (30) and one multi-faceted intervention (42) also used basic relaxation techniques and cognitive-behavioral principles respectively.Single studies used other delivery methods or tools (e.g., problem-solving, goal-setting, role play, video, and audio technology).

There were no clear patterns or differences across intervention types in terms of the delivery methods or tools used except that all psychosocial interventionsmade use of formal psychotherapeutic techniques. The median number of delivery methods used was estimated at 4, ranging from 3 in educational to 4.5 inself-management interventions.

ContentInformation on content was particularly sparse for one psychosocial intervention (33). All interventions appeared to cover asthma medication, and all but one (33)

covered the development of a general understanding of asthma (e.g., its nature, pathophysiology, causes) and aspects of asthma management, most commonlyprinciples of self-management, attack management, and use of a peak flow meter or action plan. Fourteen discussed triggers or trigger avoidance, and 7discussed regular clinic attendance. The median number of asthma-specific topics covered was estimated at 10. Multi-faceted and self-managementinterventions tended to cover a greater range than educational interventions, and these more than psychosocial interventions. After examining their detailedcontent, the distinction between educational and self-management programs appears questionable, since two studies classified as educational interventionsincluded use of formal self-management plans for at least some patients (28, 31).

All but 3 interventions (28, 36, 39) reported consideration of broader issues indirectly related to asthma and its management. Ten covered psychological issues(e.g., stress, anxiety, fears) and 9 covered social or family issues. Five studies or less covered attitudes and beliefs in relation to asthma and its management,smoking and other health-related behaviors (e.g., exercise, diet) and economic problems. Other issues (e.g., communication with providers, occupationalconcerns) were addressed by single studies. The median number of broader issues covered was estimated at 2. There was little difference in the number orcategories of issues addressed across interventions of different types except that psychosocial interventions were most likely to cover psychological issues.

Add-onsInterventions classified as multi-faceted included non–psycho-educational add-ons, all incorporating enhanced medical care (e.g. optimization of drug therapy,

altered inpatient and follow up treatment, liaison with medical services), 2 individualized exercise programs (38, 42), and 2 referral to other health,psychological, or social services (32, 42). Two educational interventions (30, 31) involved referral.

that analyses, for at least some outcomes, were undertakenon an intention-to-treat (ITT) basis. A further 2 RCTs (36, 37)and 1 prospective COS (34) in fact conducted what appearedto be equivalent to ITT analyses. Eight of the 14 RCTs (27,29, 30, 38–43), and 3 of the 4 COSs (33–35) were judged tohave adequate reporting of outcome data.

Outcomes and EffectivenessDetails of follow-ups, categories of outcomes assessed, and

a descriptive summary of findings for individual studies areprovided in Table 2.

The maximum duration of follow-up ranged from 3 months(40) to 3 years (38), with a median of 12 months (10 monthsfor RCTs). Thirteen studies had more than one follow-up,

many including a short-term assessment of outcomes, oftenduring an early intensive phase of longer interventions orsoon after the end of shorter interventions, plus a medium-and/or long-term assessment beyond the end of any interven-tion. Results are summarized and synthesized on the basisof short-, medium- and long-term categories and, where ap-propriate, across all time points using data from the latestfollow-ups reported.

All studies reported assessment of one or more health out-comes (with at least one third reporting assessment of ad-missions, A&E attendances, symptoms, health status/qualityof life, and psychological morbidity). Nine studies reportedone or more variables related to self-management (with atleast a third reporting assessment of medication use, other

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%K

)N

oL

)Y

es-m

inor

diff

eren

ces

M)

43%

N)

No

O)

Yes

P)N

oQ

)Y

es

ST(3

mos

)M

T(6

mos

)A

d,A

&E

:com

men

tson

non-

sig.

STan

dM

Tef

fect

sbu

tno

data

pres

ente

dSy

m:n

otre

port

edH

S:SM

Ds

(0.1

1,−0

.74

to0.

97;0

.10,

−0.9

9to

1.19

)ca

lcul

ated

from

mea

nov

eral

las

thm

a-sp

ecifi

cqu

ality

oflif

esc

ores

sugg

estn

on-s

ig.S

Tan

dM

Tef

fect

s(p

=0.

8,p

=0.

86,r

espe

ctiv

ely)

;no

data

pres

ente

dfr

omge

neri

csc

ale

Psy:

SMD

s(−

0.01

,−0.

86to

0.85

;0.2

2,−0

.87

to1.

32)

calc

ulat

edfr

omm

ean

depr

essi

onsc

ores

sugg

estn

on-s

ig.S

Tan

dM

Tef

fect

s(p

=0.

99,

p=

0.69

resp

ectiv

ely)

SA:c

omm

ents

onno

n-si

g.ST

and

MT

effe

cts

butn

oda

tapr

esen

ted

SM:c

omm

ents

onno

n-si

g.ST

and

MT

effe

cts

acro

ssva

riet

yof

area

sre

late

dto

adhe

renc

e,us

eof

actio

npl

an,m

onito

ring

,atte

ndan

cebu

tno

data

pres

ente

dB

rew

in&

Hug

hes,

1995

(28)

CPO

SC

oncu

rren

tcom

pari

son

grou

pse

lect

edfr

ompa

tient

sad

mitt

edto

othe

rho

spita

lsin

dist

rict

D)

Yes

E)

No

F)Y

es-

one

only

G)

45H

)Y

esI)

No

J)10

0%K

)N

/AL

)N

oM

)70

%N

)N

o

O)

No

P)N

oQ

)N

o

ST(3

–5m

os)

Sym

:com

men

tson

non-

sig.

effe

cts

onsc

ores

from

com

posi

tesy

mpt

omm

easu

repr

esen

ted

inva

riou

sw

ays

(no

pva

lues

repo

rted

)T

L:n

on-s

ig.e

ffec

tson

%ha

ving

time

off

(no

pva

lue

repo

rted

)K

n:pe

rcei

ved

know

ledg

esc

ores

sig.

high

erin

cont

rol(

p<

0.00

0001

)an

dac

tual

know

ledg

esc

ores

sig.

high

erin

inte

rven

tion

grou

p(p

=0.

0000

29)

Cas

tro

etal

.,20

03(2

9)R

CT

A)

Not

stat

edB

)Y

esC

)Se

aled

enve

lope

s

D)

No

E)

Yes

-ad

mis

sion

spr

e-sp

ecifi

edF)

Yes

-12

mos

pre-

spec

ified

G)

96H

)Y

esI)

No

J)10

0%K

)N

/AL

)Y

es-

min

ordi

ffer

ence

sM

)69

%N

)N

o

O)

Yes

P)Y

esQ

)Y

es

MT

(6m

os)

(12

mos

)A

d:si

g.LT

effe

cts

onto

taln

umbe

rs(p

=0.

04)

and

hosp

itald

ays

due

toas

thm

a(p

=0.

04),

over

alln

umbe

rs(p

=0.

04)

and

hosp

itald

ays

from

any

caus

e(p

=0.

04),

and

onm

ultip

lere

adm

issi

ons

(p=

0.03

)A

&E

:non

-sig

.LT

effe

cts

onto

taln

umbe

rs(p

=0.

52)

HS:

SMD

(0.0

7,−0

.41

to0.

55)

calc

ulat

edfr

omm

ean

over

alla

sthm

a-sp

ecifi

cqu

ality

oflif

esc

ores

sugg

ests

non-

sig.

MT

effe

cts

(p=

0.77

);al

sore

port

sno

n-si

g.M

Tef

fect

son

mea

nsu

bsca

lesc

ores

(all

p>

0.49

)SA

:non

-sig

.LT

effe

cts

onto

taln

umbe

rsof

heal

thca

repr

ovid

ervi

sits

(p=

0.82

)

Ford

etal

.,19

97(3

0)R

CT

A)

Not

stat

edB

)N

oC

)N

/A

D)

Yes

E)

Yes

–A

&E

visi

tspr

e-sp

ecifi

edF)

Yes

–12

mos

inre

sults

G)

163

H)

Yes

I)Y

esJ)

42%

K)

Yes

-si

mila

rL

)Y

es-

sim

ilar

M)

100%

N)

No

O)

Yes

P)Y

esQ

)Y

es

ST(4

mos

)M

T(8

mos

)LT

(12

mos

)

Ad,

OU

,SA

,Ex:

Not

repo

rted

for

subg

roup

ofin

tere

stA

&E

:sig

.LT

effe

cts

onm

onth

lyav

erag

eat

tend

ance

into

tals

ampl

e(p

<0.

0005

)w

ithno

diff

eren

tiale

ffec

tin

the

ethn

icm

inor

ity(p

=0.

6)su

bgro

upof

inte

rest

,bu

teff

ects

prim

arily

seen

duri

ngin

itial

4m

onth

s(p

=0.

003)

rath

erth

anla

st4

mon

ths

(p=

0.42

)H

S:si

g.LT

effe

cts

onm

onth

lyav

erag

enu

mbe

rof

limite

dac

tivity

days

into

tal

sam

ple

(p=

0.04

)w

ithno

diff

eren

tiale

ffec

tin

the

ethn

icm

inor

ity(p

=0.

43)

subg

roup

ofin

tere

st,b

utef

fect

spr

imar

ilyse

enin

initi

al4

mon

ths

(p=

0.03

)ra

ther

than

last

4m

onth

s(p

=0.

65)

Kn,

Bel

:eff

ects

onov

eral

lsam

ple

notf

orm

ally

asse

ssed

butr

epor

ted

that

nodi

ffer

entia

leff

ects

byra

ce(p

=0.

51fo

rin

tera

ctio

n)G

arre

ttet

al.,

1994

(31)

RC

TA

)N

otst

ated

B)

No

C)

N/A

D)

Yes

E)

No

F)Y

es-o

neon

ly

G)

500

H)

Yes

I)Y

esJ)

51%

K)

Yes

-non

-pa

rtic

ipan

tsyo

unge

r,ad

mis

sion

rate

ssi

mila

rL

)Y

es-s

imila

rM

)>

90%

N)

Yes

–sim

ilar

O)

Yes

P)Y

es-

for

som

eou

tcom

esQ

)N

o

MT

(9m

os)

Ad:

RR

(0.7

9,0.

45to

1.39

,p

=0.

42)

calc

ulat

edfr

om%

ofto

tals

ampl

ead

mitt

edsu

gges

tsno

n-si

g.ef

fect

sfa

vori

ngin

terv

entio

nA

E:R

R(1

.03,

0.80

to1.

32,

p=

0.83

),ca

lcul

ated

from

%of

tota

lsam

ple

atte

ndin

gsu

gges

tsno

n-si

g.ef

fect

sSy

m:s

ig.e

ffec

tson

%to

tals

ampl

ew

akin

gat

nigh

t(p

=0.

02),

coug

hing

(p=

0.05

)an

dex

peri

enci

ngbr

eath

less

ness

(p=

0.05

);co

mm

ents

onno

n-si

g.ef

fect

son

othe

rsy

mpt

omm

easu

res

butn

oda

tare

port

edH

S:co

mm

ents

onno

n-si

g.ef

fect

sbu

tno

data

repo

rted

OU

:RR

(0.7

8,0.

53to

1.14

)ca

lcul

ated

from

%ad

ults

atte

ndin

gfo

rur

gent

GP

care

sugg

ests

non-

sig.

effe

cts

favo

urin

gin

terv

entio

nPs

y:no

n-si

g.ef

fect

son

%ad

ults

with

anxi

ety/

pani

cat

time

ofat

tack

(p=

0.25

)M

ed:s

ig.e

ffec

tson

use

ofpr

even

tive

med

icat

ion

inad

ults

(p<

0.00

05)

butd

ata

onth

isan

dot

her

aspe

cts

ofm

edic

atio

nus

eno

trep

orte

dSA

:com

men

tson

non-

sig.

effe

cts

butn

oda

tare

port

edR

F:no

n-si

g.ef

fect

son

%to

tals

ampl

ein

diff

eren

tcat

egor

ies

ofpe

akflo

wva

riab

ility

(p=

0.08

)Se

v:si

g.ef

fect

son

%to

tals

ampl

ere

port

ing

perc

eive

dim

prov

emen

tin

seve

rity

(p=

0.00

05)

TL

:non

-sig

.eff

ects

on%

tota

lsam

ple

with

days

abse

nt(p

=0.

3)SM

:sig

.eff

ects

on%

adul

tsw

ithan

actio

npl

an(p

<0.

01),

havi

ngan

dus

ing

peak

flow

met

erco

rrec

tly(p

<0.

005)

and

adeq

uate

lym

anag

ing

slow

(p<

0.00

5)an

dfa

st-o

nset

(p<

0.01

)at

tack

s;no

n-si

g.ef

fect

son

inha

ler

tech

niqu

e(p

>0.

01);

com

men

tson

non-

sig.

effe

cts

onsm

okin

gan

dad

here

nce

butn

oda

tare

port

edSS

:sig

.eff

ects

on%

adul

tsha

ving

som

eone

tohe

lpw

ithan

asth

ma

atta

cks

(p<

0.05

)

230

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

ichi

gan

Uni

vers

ity o

n 10

/31/

14Fo

r pe

rson

al u

se o

nly.

Geo

rge

etal

.,19

99(3

2)R

CT

A)

Ran

dom

num

ber

tabl

eB

)N

oC

)N

/A

D)

No

E)

No

F)Y

es-o

neon

lyfo

rm

ain

outc

omes

G)

77H

)Y

esI)

No

J)88

%K

)N

oL

)Y

es-s

imila

rM

)65

%N

)N

o

O)

Yes

P)Y

es-

for

som

eou

tcom

esQ

)N

o

ST(1

mo)

MT

(6m

os)

Ad:

sig.

MT

effe

cts

onto

taln

umbe

r(p

=0.

04)

butn

on-s

ig.e

ffec

tson

mea

nle

ngth

ofst

ay(p

=0.

12)

A&

E:s

ig.M

Tef

fect

son

tota

lnum

ber

(p=

0.04

)SA

:sig

.ST

effe

cts

onat

tend

ance

atou

tpat

ient

appo

intm

ents

(p=

0.01

)

Gro

en&

Pels

er,

1960

(33)

CR

OS

Ret

rosp

ectiv

eid

entifi

catio

nof

grou

psre

ceiv

ing

diff

eren

ttr

eatm

ents

atsa

me

cent

er

D)

No

E)

Yes

-sev

erity

only

F)Y

es-o

neon

ly

G)

162

H)

Yes

I)N

oJ)

100%

K)

N/A

L)

Yes

-age

diff

eren

ces

adju

sted

for

M)

91%

N)

No

O)

Yes

P)N

/AQ

)Y

es

LT(1

+yr

)D

:sig

.eff

ecto

nnu

mbe

rde

ad(p

=0.

0004

)bu

tsig

.los

twhe

nad

just

edfo

rag

e(p

=0.

14)

Sev:

sig.

effe

cton

num

ber

impr

oved

(p=

0.00

04),

mai

ntai

ned

afte

rad

just

men

tfor

age

(p=

0.00

005)

Kel

soet

al.,

1995

(34)

CPO

SC

ontr

olgr

oup

mee

ting

sam

ecr

iteri

aan

dtr

eate

dat

sam

etim

e,re

tros

pect

ivel

y,id

entifi

edfr

omot

her

hosp

itals

inar

ease

rvin

gsi

mila

rpo

pula

tion

(low

-inc

ome,

Afr

ican

-Am

eric

ans)

D)

No

E)

No

F)Y

es-o

neon

ly

G)

52H

)Y

esI)

No

J)N

otst

ated

K)

No

L)

Yes

-dif

fere

nces

inag

e&

adul

t-on

set

asth

ma

adju

sted

for

M)

Not

stat

edN

)N

o

O)

No

P)N

o-bu

tac

tual

lydo

neQ

)Y

es

LT(1

2m

os)

Ad:

non-

sig.

effe

cts

onav

erag

enu

mbe

rof

adm

issi

ons

(p=

0.37

)A

&E

:sig

.eff

ects

onav

erag

enu

mbe

rof

atte

ndan

ces

(p<

0.01

)M

ed,S

M,K

n:re

port

edfo

rin

terv

entio

ngr

oup

only

Kel

soet

al.,

1996

(35)

CPO

SC

ontr

olgr

oup

retr

ospe

ctiv

ely

iden

tified

via

char

trev

iew

D)

No

E)

No

F)N

o

G)

39H

)Y

esI)

No

J)N

otst

ated

K)

No

L)

Yes

-sim

ilar

M)

Not

stat

edN

)N

o

O)

Yes

P)N

oQ

)Y

es

LT(1

yr&

2yr

s)A

d:si

g.ef

fect

son

mea

nnu

mbe

rof

adm

issi

ons

(p<

0.05

at1

and

2ye

ars)

A&

E:s

ig.e

ffec

tson

mea

nnu

mbe

rof

atte

ndan

ces

(p<

0.05

at1

and

2ye

ars)

HS,

Med

,Kn:

repo

rted

for

inte

rven

tion

grou

pon

lySy

m:N

oou

tcom

eda

tare

port

edD

:1in

inte

rven

tion

grou

pIT

U:1

inin

terv

entio

n(l

ater

died

),2

inco

ntro

lgro

up

May

oet

al.,

1990

(36)

RC

TA

)Pa

tient

reco

rdnu

mbe

rB

)N

oC

)N

/A

D)

No

E)

Yes

-ad

mis

sion

sin

resu

ltsF)

Yes

-one

only

G)

104

H)

Yes

I)N

oJ)

100%

K)

N/A

L)

Yes

-sim

ilar

M)

100%

N)

No

O)

Yes

P)N

o-bu

tac

tual

lydo

neQ

)N

o

MT

(max

.8m

os)

Ad:

sig.

effe

cts

onnu

mbe

r(p

<0.

004)

and

days

per

patie

nt(p

<0.

02)

Med

:rep

orte

dfo

rin

terv

entio

ngr

oup

only

D:1

deat

hin

cont

rolg

roup

Mor

ice

&W

renc

h,20

01(3

7)

RC

TA

)N

otst

ated

B)

No

C)

N/A

D)

No

E)

No

F)N

o

G)

80H

)Y

esI)

No

J)N

otst

ated

K)

No

L)

Yes

-min

ordi

ffer

ence

sM

)75

%N

)N

o

O)

Yes

P)N

o-bu

tac

tual

lydo

nefo

rso

me

outc

omes

Q)

No

ST(6

wks

)M

T(6

mos

)LT

(18

mos

)

Ad:

RR

(0.9

1,0.

44to

1.90

,p

=0.

80)

calc

ulat

edfr

omnu

mbe

rof

patie

nts

adm

itted

sugg

este

dno

n-si

g.LT

effe

cts

favo

ring

inte

rven

tion

A&

E:R

R(5

.00,

0.25

to10

0.97

,p

=0.

29)

calc

ulat

edfr

omnu

mbe

rof

patie

nts

atte

ndin

gsu

gges

tsno

n-si

g.LT

effe

cts

favo

ring

cont

rol

OU

:RR

(0.9

3,0.

50to

1.72

)ca

lcul

ated

from

num

ber

ofpa

tient

sha

ving

urge

ntG

Pvi

sits

/cal

l-ou

tssu

gges

tsno

n-si

g.M

Tef

fect

sfa

vori

ngin

terv

entio

nM

ed:s

ig.M

Tef

fect

son

beta

-ago

nist

use

(p<

0.01

)(s

elec

tive

repo

rtin

g)SM

:sig

.ST

and

MT

effe

cts

on%

with

wri

tten

man

agem

entp

lan

(p<

0.00

1,p

<0.

001)

,sig

.ST

effe

cts

onus

eof

peak

flow

met

er(p

<0.

005)

and

know

ledg

eof

peak

flow

(p<

0.01

),si

g.M

Tef

fect

son

%pe

rfor

min

gva

riou

sap

prop

riat

eac

tions

(p<

0.01

)(b

utda

taon

thes

eno

tfor

mal

lyre

port

ed)

Nat

hell,

2005

(38)

RC

TA

)C

ompu

teri

zed

list

B)

Yes

C)

Con

duct

edby

inde

pend

ent

rese

arch

er

D)

No

E)

Yes

–sic

kle

ave

pre-

spec

ified

F)N

o

G)

197

H)

Yes

I)N

oJ)

83%

K)

Yes

-sim

ilar

L)

Yes

-sim

ilar

M)

89%

N)

No

O)

Yes

P)Y

esQ

)Y

es

LT(1

,2&

3yr

s)T

L:n

on-s

ig.e

ffec

tson

over

allm

edia

nsi

ckle

ave

days

at1

(p=

0.47

),2

(p=

0.18

)an

d3

year

s(p

=0.

12),

buts

ig.e

ffec

tsat

3ye

ars

onsu

bgro

upw

ithpr

evio

usph

ysic

ian

diag

nosi

sof

asth

ma

and

non-

smok

ers

(bot

hp

=0.

02)

Med

:sig

.eff

ects

on%

usin

gin

hale

dst

eroi

dsat

1(p

=0.

03)

butn

ot2

(p=

0.13

)or

3ye

ars

(p=

0.88

)SM

:non

-sig

.eff

ects

on%

smok

ing

at1

(p=

0.45

),2

(p=

0.87

)or

3ye

ars

(p=

0.88

)

(Con

tinu

edon

next

page

)

231

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

ichi

gan

Uni

vers

ity o

n 10

/31/

14Fo

r pe

rson

al u

se o

nly.

TAB

LE

2.—

Met

hodo

logi

calq

ualit

ych

arac

teri

stic

s,fo

llow

-ups

repo

rted

,out

com

esas

sess

ed,a

ndsu

mm

ary

findi

ngs

inin

divi

dual

stud

ies.

(Con

tinu

ed)

Met

hodo

logi

cald

etai

ls&

qual

ityas

sess

men

t

Stud

yD

esig

nR

ando

miz

atio

n/se

lect

ion

ofco

ntro

ls∗

Out

com

eas

sess

men

t∗Sa

mpl

e&

attr

ition

∗A

naly

sis

&re

port

ing∗

Follo

w-u

ps†

Out

com

esas

sess

ed‡

and

sum

mar

yfin

ding

s(i

nclu

ding

rela

tive

risk

s(R

R)

and

stan

dard

ized

mea

ndi

ffer

ence

s(S

MD

),95

%co

nfide

nce

inte

rval

sw

here

able

tobe

calc

ulat

ed)

Osm

anet

al.,

2002

(39)

RC

TA

)R

ando

mnu

mbe

rta

ble

B)

Yes

C)

Seri

ally

num

bere

den

velo

pes

D)

Yes

E)

Yes

-ad

mis

sion

spr

e-sp

ecifi

edF)

Yes

–12

mos

pre-

spec

ified

G)

280

H)

Yes

I)Y

esJ)

60%

K)

No

L)

Yes

-dif

fere

nces

inge

nder

adju

sted

for

M)

95%

N)

No

O)

Yes

P)N

oQ

)Y

es

ST(1

mo)

LT(1

2m

os)

Ad:

RR

sca

lcul

ated

from

num

ber

ofpa

tient

sad

mitt

edsu

gges

tsno

n-si

g.ST

effe

ctfa

vori

ngin

terv

entio

n(0

.27,

0.03

to2.

41,

p=

0.24

),si

g.LT

effe

ctfa

vori

ngin

terv

entio

n(0

.62,

0.39

to0.

99,

p=

0.04

)w

hich

non-

sig.

whe

nan

alys

isco

nfine

dto

subg

roup

with

prev

ious

adm

issi

ons

(0.8

8,0.

54to

1.44

,p

=0.

62)

Sym

:sig

.ST

effe

cts

on%

expe

rien

cing

day

and

nigh

t-tim

esy

mpt

oms

(bot

hp

=0.

01),

non-

sig.

effe

cts

on%

expe

rien

cing

rest

rict

ions

toac

tivity

(p=

0.12

),bu

tnon

-sig

.eff

ects

whe

nan

alys

isco

nfine

dto

subg

roup

with

prev

ious

adm

issi

ons

(p=

0.70

,0.3

3,0.

17re

spec

tivel

y)Sa

t:si

g.ST

effe

cts

on%

into

tals

ampl

ean

dsu

bgro

upw

ithpr

evio

usad

mis

sion

ssa

tisfie

dw

ithca

re(p

<0.

001)

Pute

tal.,

2003

(40)

RC

TA

)D

raw

ing

enve

lope

B)

Yes

C)

Seal

ed,n

on-t

rans

pare

nten

velo

pes

D)

Yes

E)

No

F)N

o

G)

25 H)

No

I)N

oJ)

51%

K)N

oL

)Y

es–c

ontr

ols

pres

crib

edm

ore

antic

holin

ergi

cs,

othe

rwis

esi

mila

rM

)39

%N

)N

o

O)

Yes

P)N

oQ

)Y

es

ST(1

.pos

t-tr

eatm

ent

(act

ual

timep

oint

not

stat

ed)

for

inte

rven

tion

&3

mos

for

cont

rol.

2.3

mos

for

inte

rven

tion

&6

mos

for

cont

rol)

Sym

:sig

.eff

ects

onm

ean

obst

ruct

ion

(p=

0.04

),fa

tigue

(p=

0.00

1)an

dir

rita

tion

(p=

0.03

)bu

tnot

dysp

nea,

hype

rven

tilat

ion

oran

xiet

ysu

bsca

lesc

ores

(pva

lues

for

latte

rno

trep

orte

d)R

F:si

g.ef

fect

son

mea

nda

y(p

=0.

03)

and

nigh

t-tim

e(p

=0.

04)

peak

flow

rate

sH

S:SM

D(1

.18,

0.28

to2.

08)

calc

ulat

edfr

omm

ean

over

alla

sthm

a-sp

ecifi

cqu

ality

oflif

esc

ores

sugg

ests

sig.

effe

ct(p

=0.

01);

also

repo

rts

sig.

effe

cts

onm

ean

activ

itylim

itatio

n(p

<0.

0001

),sy

mpt

om(p

<0.

0001

)an

dem

otio

n(p

=0.

003)

(p<

0.00

01),

butn

oten

viro

nmen

tsub

scal

esc

ores

(pva

lue

not

repo

rted

)Ps

y:SM

D(−

1.23

,−2.

14to

−0.3

2)ca

lcul

ated

from

mea

nne

gativ

eem

otio

nalit

ysc

ores

sugg

ests

sig.

effe

ct(p

=0.

008)

SM:s

ig.e

ffec

tson

mea

nad

here

nce

scor

es(p

=0.

002)

SE,B

el,K

n:si

g.ef

fect

son

mea

nse

lf-e

ffica

cy(p

=0.

008)

,atti

tude

(p<

0.00

01)

and

know

ledg

e(p

<0.

0001

)su

bsca

lesc

ores

ofas

thm

a-sp

ecifi

cqu

estio

nnai

reR

oss

etal

.,20

05(4

1)R

CT

A)

Not

stat

edB

)N

oC

)N

/A

D)

No

E)

No

F)N

o

G)

34H

)Y

esI)

No

J)71

%K

)Y

es-s

imila

rL

)Y

es–i

nter

vent

ion

grou

pm

ore

seve

reas

thm

a,ot

herw

ise

sim

ilar

M)

74%

N)

Yes

–si

mila

r

O)

Yes

P)N

oQ

)Y

es

ST(8

wks

),M

T(6

mos

for

inte

rven

tion

only

)

Psy:

SMD

(−0.

52,−

1.36

to0.

32)

calc

ulat

edfr

omm

ean

depr

essi

vesy

mpt

oms

scor

essu

gges

tsno

n-si

g.ef

fect

favo

ring

inte

rven

tion

(p=

0.23

);al

sore

port

ssi

g.ST

effe

cts

onto

taln

umbe

rof

pani

cat

tack

s(p

=0.

03),

mea

nto

tals

core

son

scal

esas

sess

ing

inte

nsity

ofan

xiet

ysy

mpt

oms

(p<

0.01

)an

dfe

arof

anxi

ety-

rela

ted

bodi

lyse

nsat

ions

(p<

0.01

)w

hich

rem

aine

dap

pare

ntto

6m

onth

s,bu

tnon

-sig

.ST

effe

cts

onm

ean

scor

esof

agro

phob

icav

oida

nce

(p=

0.2)

RF:

sig.

STef

fect

son

mea

nm

orni

ngpe

akflo

wra

te(p

<0.

05)

butn

on-s

ig.e

ffec

tson

peak

flow

vari

abili

ty(p

=0.

14)

Sym

:SM

D(−

0.19

,−1.

07to

0.69

)ca

lcul

ated

from

mea

nda

ysw

ithsy

mpt

oms

sugg

ests

non-

sig.

STef

fect

favo

ring

inte

rven

tion

(p=

0.68

).H

S:SM

D(0

.67,

−0.1

8to

1.53

)ca

lcul

ated

from

mea

nov

eral

last

hma-

spec

ific

qual

ityof

life

scor

essu

gges

tsno

n-si

g.ST

effe

ctfa

vori

ngin

terv

entio

n(p

=0.

12).

Smith

etal

.,20

05(4

2)R

CT

A)

Com

pute

rge

nera

ted

list

B)

No

C)

N/A

D)

No

E)

Yes

-sy

mpt

oms

pre-

spec

ified

F)Y

es–6

mos

pre-

spec

ified

G)

92H

)Y

esI)

Yes

J)51

%K

)Y

es-n

on-

part

icip

ants

mor

elik

ely

mal

ean

dno

n-at

tend

ers

atcl

inic

L)

Yes

-dif

fere

nces

inge

nder

&ed

ucat

ion

adju

sted

for

M)

83%

N)

Yes

–sim

ilar

O)

Yes

P)Y

esQ

)Y

es

ST(2

mos

)M

T(6

mos

)LT

(12

mos

)

Ad:

RR

sca

lcul

ated

from

num

ber

ofpa

tient

sad

mitt

edsu

gges

tsno

n-si

g.M

T(1

.55,

0.72

to3.

32,

p=

0.26

)an

dLT

effe

cts

(1.2

6,0.

67to

2.37

,p

=0.

48)

favo

ring

cont

rol(

addi

tiona

ldat

apr

ovid

edby

auth

ors)

A&

E:R

Rs

calc

ulat

edfr

omnu

mbe

rof

patie

nts

atte

ndin

gsu

gges

tsno

n-si

g.M

T(1

.59,

0.64

to3.

95,

p=

0.32

)an

dLT

effe

cts

(1.1

6,0.

65to

2.15

,p

=0.

62)

favo

ring

cont

rol(

addi

tiona

ldat

apr

ovid

edby

auth

ors)

Med

:sig

.ST

effe

cts

onbe

ta-a

goni

stus

e(p

=0.

04),

notm

aint

aine

din

MT

(p=

0.2)

Sym

:SM

Dca

lcul

ated

from

mea

nsc

ores

onco

mpo

site

sym

ptom

scal

esu

gges

tno

n-si

g.ST

effe

cts

favo

ring

inte

rven

tion

(−0.

22,−

0.65

to0.

21,

p=

0.31

)an

dno

n-si

g.M

T(0

.06,

−0.3

6to

0.49

,p

=0.

77)

and

LTef

fect

s(−

0.04

,−0.

46to

0.39

,p

=0.

87).

HS:

sig.

ST(p

=0.

01),

MT

(p=

0.01

)an

dLT

effe

cts

(p=

0.03

)on

mea

nas

thm

a-sp

ecifi

cqu

ality

-of-

life

scor

esse

enon

lyfr

omfu

llyad

just

edan

alys

es,

othe

rwis

eno

n-si

g.ef

fect

s(a

llp

>0.

56);

non-

sig.

ST(p

=0.

78,

p=

0.60

),M

T(p

=0.

67,

p=

0.94

)an

dLT

effe

cts

(p=

0.80

,p

=0.

56)

resp

ectiv

ely

onm

ean

phys

ical

func

tion

and

men

talh

ealth

subs

cale

scor

esfr

omge

neri

cqu

estio

nnai

rePs

y:SM

Ds

(0.1

0,−0

.33

to0.

53;0

.27,

−0.1

6to

0.70

;0.0

2,−0

.41

to0.

44)

calc

ulat

edfr

omm

ean

depr

essi

onsc

ores

sugg

estn

on-s

ig.S

T,M

Tan

dLT

effe

cts

(p=

0.66

;p

=0.

22;

p=

0.94

resp

ectiv

ely)

;als

ore

port

sno

clea

ref

fect

son

mea

nan

xiet

yor

gene

ralp

sych

olog

ical

mor

bidi

tysc

ores

,for

mal

anal

yses

not

unde

rtak

enSM

:no

clea

rST

,MT

orLT

effe

cts

onm

ean

adhe

renc

esc

ores

,%sm

okin

gor

iden

tifyi

ngad

ditio

nalt

rigg

ers,

form

alan

alys

esno

tund

erta

ken

SE:n

ocl

ear

ST,M

Tor

LTef

fect

son

mea

npe

rcei

ved

cont

rolo

fas

thm

asc

ores

,fo

rmal

anal

yses

notu

nder

take

n

232

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

ichi

gan

Uni

vers

ity o

n 10

/31/

14Fo

r pe

rson

al u

se o

nly.

Yoo

net

al.,

1993

(43)

RC

TA

)N

otst

ated

B)

No

C)

N/A

D)

Yes

E)

No

F)Y

es-1

0m

osin

resu

lts

G)

76H

)Y

esI)

No

J)41

%K

)Y

es-w

omen

,no

n-sm

oker

s,th

ose

with

phys

icia

nm

ore

likel

yto

part

icip

ate

L)

Yes

-sim

ilar

M)

74%

N)

No

O)

Yes

P)N

oQ

)Y

es

ST(5

mos

)M

T(1

0m

os)

Ad:

RR

(0.1

5,0.

02to

1.17

,p

=0.

07)

calc

ulat

edfr

omnu

mbe

rof

patie

nts

adm

itted

sugg

ests

non-

sig.

MT

effe

ctfa

vori

ngin

terv

entio

nA

&E

:RR

(0.4

5,0.

13to

1.62

,p

=0.

22)

calc

ulat

edfr

omnu

mbe

rof

patie

nts

adm

itted

sugg

ests

non-

sig.

MT

effe

cts

favo

ring

inte

rven

tion

RF:

sig.

effe

cts

onpr

even

tion

ofde

clin

esin

mea

nFE

V1

and

FVC

inST

(p=

0.01

,p

<0.

05,r

espe

ctiv

ely)

butn

otM

T(n

op

valu

esre

port

ed);

com

men

tson

little

effe

cton

mea

npe

akflo

wva

riab

ility

(no

pva

lues

repo

rted

)Se

v:no

n-si

g.M

Tef

fect

son

mea

npe

rcei

ved

seve

rity

scor

es(p

=0.

85)

Sym

:SM

D(−

0.10

,−0.

62to

0.42

,p

=0.

71)

calc

ulat

edfr

omm

ean

scor

eson

com

posi

tesy

mpt

omsc

ale

sugg

estn

on-s

ig.M

Tef

fect

sfa

vori

ngin

terv

entio

nT

L:n

on-s

ig.M

Tef

fect

son

%ab

sent

for>

2w

eeks

(pva

lue

notr

epor

ted)

Psy:

SMD

(0.0

1,−0

.51

to0.

53)

calc

ulat

edfr

omm

ean

scor

esfo

rps

ycho

soci

aldi

stur

banc

edu

eto

asth

ma

sugg

ests

non-

sig.

MT

effe

cts

(p=

0.97

)SM

:sig

.MT

effe

cts

onm

ean

scor

esfo

rus

eof

anac

tion

plan

(p<

0.00

1)an

ddi

ffer

entia

tion

ofm

ildfr

omse

vere

atta

cks

(p=

0.00

5)K

n:si

g.M

Tef

fect

son

mea

nsc

ores

for

know

ledg

eof

asth

ma

(p<

0.07

)an

dm

edic

atio

ns(p

<0.

05)

Bel

:sig

.MT

effe

cts

onm

ean

scor

esfo

rap

prop

riat

ehe

alth

belie

fs(p

<0.

001)

∗ Met

hodo

logi

cald

etai

lsan

dqu

ality

crite

ria

asse

ssed

:A)

Ran

dom

izat

ion

met

hod,

B)

Con

ceal

edal

loca

tion?

,C)

Con

ceal

men

tmet

hod,

D)

Blin

ded

outc

ome

asse

ssm

ent?

E)

Sing

lepr

imar

you

tcom

esp

ecifi

ed/r

epor

ted?

F)Si

ngle

prim

ary

endp

oint

spec

ified

?G

)To

tals

ampl

esi

ze,H

)C

lear

sele

ctio

ncr

iteri

a?,I

)Po

wer

calc

ulat

ion?

,J)

Part

icip

atio

nra

te,K

)C

ompa

rabi

lity

ofno

n-pa

rtic

ipan

tsch

ecke

d?,L

)B

asel

ine

com

para

bilit

yof

grou

psch

ecke

d?,M

)M

inim

umfo

llow

-up,

N)

Com

para

bilit

yof

with

draw

als

chec

ked?

O)P

rovi

ded

deta

ilsof

anal

ysis

?P)

Spec

ified

ITT

anal

ysis

?Q

)Ade

quat

eou

tcom

ere

port

ing

(num

erat

oran

dde

nom

inat

orfo

rbin

ary

outc

omes

,poi

ntes

timat

espl

usm

easu

res

ofva

riab

ility

forc

ontin

uous

data

)? † Fol

low

-up:

Thi

sw

asst

anda

rdiz

ed,a

sfa

ras

poss

ible

,to

repr

esen

tfol

low

-up

from

the

star

tof

the

inte

rven

tion

orba

selin

eas

sess

men

t(as

sum

edto

becl

ose

toge

ther

)an

dta

ken

asth

eav

erag

edu

ratio

nor

mid

-poi

ntof

ara

nge

whe

rele

ngth

offo

llow

-up

vari

edac

ross

indi

vidu

alpa

tient

sw

ithin

stud

ies,

and

was

cate

gori

zed

into

shor

t-te

rm(S

T)=

0to

<6

mon

ths;

med

ium

-ter

m(M

T)=

6to

<12

mon

ths;

and

long

-ter

m(L

T)=

12+

mon

ths.

‡ Out

com

eca

tego

ries

:Ad

=ho

spita

ladm

issi

ons/

read

mis

sion

s,A

&E

=A

&E

/ED

atte

ndan

ces,

OU

=O

ther

unsc

hedu

led

heal

thca

reat

tend

ance

s,SA

=sc

hedu

led

heal

thca

reat

tend

ance

s,M

ed=

med

icat

ion

use,

Ex

=ex

acer

batio

ns,T

L=

time

lost

from

wor

k,Sy

m=

sym

ptom

s/as

thm

aco

ntro

l,Se

v=

seve

rity

,RF

=re

spir

ator

yfu

nctio

n,H

S=

heal

thst

atus

/qua

lity

oflif

e,Ps

y=

psyc

holo

gica

lmor

bidi

ty,S

M=

self

-man

agem

entb

ehav

ior,

SE=

self

-effi

cacy

/per

ceiv

edco

ntro

l,B

el=

belie

fs/a

ttitu

des,

Kn

=kn

owle

dge,

SS=

soci

alsu

ppor

t.

233

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

ichi

gan

Uni

vers

ity o

n 10

/31/

14Fo

r pe

rson

al u

se o

nly.


self-management behaviors, and knowledge). The number ofoutcome categories assessed per study ranged from 2 (33) to13 (31), with a median of 4, although the number for whichcomparative, numerical outcome data were actually reportedand could thus be considered in synthesising results (Table 3)was often less.

No studies reported statistically significant effects favoringcontrol groups, and only one small RCT (n = 27) failed toshow any significant positive effects of psycho-educationalinterventions (27). The main analyses from 9 of the 13 RCTsand 3 of the 4 COSs showed statistically significant impactson one or more health outcomes. Eight of the nine studiesreporting self-management outcomes, including four that didnot find any significant impacts on health outcomes (28, 37,38, 42), showed significant effects on one or more aspects ofself-management. However, in several studies (28, 29, 34, 36,38, 42) effects were confined to isolated outcomes at singletime points. Only two very small RCTs (n < 35) (40,41)showed consistent statistically significant effects across alloutcomes reported.

Table 3 presents a summary of findings in relation to out-comes reported as assessed by at least four studies, thus al-lowing meaningful synthesis. Qualitative syntheses of indi-vidual study results show a lack of positive effects of psycho-educational interventions on health status/quality of life, psy-chological morbidity and time lost from work, conflictingfindings with respect to admissions, A&E attendances andsymptoms, and mainly positive effects on various aspects ofself-management, medication use, knowledge, and respira-tory function. However, most of the latter were assessed bysmall numbers of studies and any positive effects appear tobe mainly short term.

Calculation of meaningful summary statistics and lim-ited quantitative syntheses were able to be undertakenfor several health outcomes for which there were a suffi-cient number of RCTs measuring and adequately reportingoutcomes in similar ways. Generally, these studies were of

FIGURE 2.—Forest plot showing meta-analysis, divided by asthma subgroups (likely and definite targetting), of relative risks ratios (RR) calculated from proportionsof adults admitted for asthma at latest follow-up reported by studies.

higher quality than others. Using data from the latest follow-ups reported, pooled estimates summarized in Table 3 sug-gest that psycho-educational interventions have little effecton A&E attendances (RR = 1.03, 0.82 to 1.29, p = 0.8)or composite symptom measures (SMD = −0.08, −0.39 to0.23, p = 0.63), and small but nonsignificant effects on ad-missions (RR = 0.79, 0.55 to 1.14, p = 0.21; Figure 2),asthma-specific quality of life (SMD = 0.45, −0.07 to 0.98,p = 0.09; Figure 3), and psychological morbidity (e.g., de-pression) (SMD = 0.17, −0.15 to 0.49, p = 0.30; Figure4). Effects on symptoms, quality of life, and psychologicalmorbidity appeared greater in the short term (Table 3).

Sensitivity analyses demonstrate that admissions andquality-of-life data were sensitive to the analysis methodsused: Statistically significant effects were observed (RR =0.75, 0.56 to 0.99, p = 0.04; SMD = 0.36, 0.00 to 0.72,p = 0.05, respectively) when a fixed effects model was ap-plied and for admissions when odds-ratio statistics were cal-culated (OR = 0.70, 0.49 to 0.99, p = 0.04) (Table 3). Lim-ited subgroup analyses suggest that significant positive ef-fects of psycho-educational interventions on admissions andquality of life observed across studies with “likely” targeting,do not extend to studies with “definite” targeting (Figures 2,3). Small but nonsignificant effects on psychological mor-bidity are also largely eliminated when analyses are confinedto studies of the most at-risk patients (Figure 4). Further-more, subgroup analyses of higher-risk patients in individualstudies suggest a similar pattern with respect to symptoms(29) and time lost from work (28). The relative effectivenessof different intervention types could not be examined sinceall meta-analyses included studies examining at least threedifferent types.

DISCUSSION

Principal FindingsThere is a recent and growing literature on psycho-

educational interventions for adults with severe and difficult

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

ichi

gan

Uni

vers

ity o

n 10

/31/

14Fo

r pe

rson

al u

se o

nly.

TAB

LE

3.—

Num

bers

ofst

udie

sas

sess

ing

and

repo

rtin

gad

equa

teda

tafo

rdi

ffer

ent

cate

gori

esof

outc

omes

and

synt

hese

sof

findi

ngs

from

thes

ein

shor

t-(S

T),

med

ium

-(M

T)

and

long

-ter

m(L

T)

(whe

re0

=no

nsig

nific

ante

ffec

ts;+

=si

gnifi

cant

effe

cts

ofps

ycho

-edu

catio

nali

nter

vent

ion

com

pare

dto

usua

lcar

e).

No.

ofst

udie

sre

port

ing

asse

ssm

ento

fou

tcom

e

No.

ofst

udie

sno

tre

port

ing

com

para

tive

num

eric

alda

tafo

rou

tcom

e

No.

ofan

dfin

ding

sfr

omst

udie

sre

port

ing

adeq

uate

com

para

tive

num

eric

alou

tcom

eda

tafr

omw

hich

mea

ning

ful

sum

mar

yst

atis

tics

for

met

a-an

alys

isco

uld

notb

eca

lcul

ated

Type

ofou

tcom

eC

OSs

RC

Ts

CO

SsR

CT

sC

OSs

RC

Ts

No.

ofan

dfin

ding

sfr

omR

CT

sre

port

ing

data

suita

ble

for

incl

usio

nin

met

a-an

alys

esR

CT

s

Sum

mar

yfin

ding

s,in

clud

ing

pool

edes

timat

es(R

R/S

MD

,95

%co

nfide

nce

inte

rval

s)fr

omm

eta-

anal

yses

and

any

subg

roup

and

sens

itivi

tyan

alys

esw

here

able

tobe

unde

rtak

en

Adm

issi

on/r

e-ad

mis

sion

210

02

(27,

30)

2LT

:0,+

(34,

35)

3M

T:+

,+(3

2,36

)LT

:+(2

9)5

ST:0

(39)

MT

:0,0

,0(3

1,42

,43)

LT:0

,0,+

(37,

42,3

9)

ST:O

nly

one

stud

yex

amin

ing

effe

cts.

MT

:5in

divi

dual

stud

ies

show

confl

ictin

gfin

ding

s,po

oled

estim

ate

acro

ss3

stud

ies

(RR

=0.

83,0

.35

to1.

94)

sugg

ests

asm

alla

ndno

n-si

g.ef

fect

(p=

0.67

).LT

:6in

divi

dual

stud

ies

show

confl

ictin

gfin

ding

sw

ithon

lycl

earl

ysi

g.ef

fect

sfr

oman

RC

Tco

nfine

dto

sing

lest

udy

ofa

mul

ti-fa

cete

din

terv

entio

n.Po

oled

estim

ate

acro

ss3

stud

ies

(RR

=0.

85,0

.55

to1.

32,)

sugg

ests

asm

alla

ndno

n-si

g.ef

fect

(p=

0.47

),w

hich

elim

inat

edw

hen

data

from

ahi

gher

risk

subg

roup

inon

est

udy

wer

eus

edin

anal

ysis

(RR

=0.

99,0

.70

to1.

39,

p=

0.94

).O

vera

ll(m

in.f

ollo

w-u

p=

6m

os):

10in

divi

dual

stud

ies

show

confl

ictin

gfin

ding

s.Po

oled

estim

ate

acro

ss5

stud

ies

(RR

=0.7

9,0.

55to

1.14

)su

gges

tsa

smal

land

non-

sig.

effe

ct(p

=0.

21)

(Fig

ure

2).H

owev

er,t

his

was

ofbo

rder

line

sign

ifica

nce

whe

na

fixed

effe

cts

mod

el(R

R=0

.75,

0.56

to0.

99,

p=

0.04

)or

odds

-rat

iost

atis

ticw

asus

ed(O

R=0

.70,

0.49

to0.

99,

p=

0.04

).Po

oled

estim

ate

(RR

=0.7

0,0.

50to

0.97

)fr

omsu

bgro

upan

alys

isin

whi

ch4

stud

ies

with

likel

yta

rget

ing

wer

eco

nsid

ered

sepa

rate

lyfr

omon

lyst

udy

with

defin

iteta

rget

ing

show

edsi

g.ef

fect

(p=

0.03

).Su

bgro

upan

alys

isof

high

er-r

isk

patie

nts

inon

ein

divi

dual

stud

yan

dth

isse

nsiti

vity

anal

ysis

sugg

estt

hata

nypo

sitiv

eef

fect

son

adm

issi

ons

inth

ose

with

seve

reas

thm

am

ayno

text

end

topa

tient

sw

ithm

ultip

leri

skfa

ctor

s.A

&E

/ED

atte

ndan

ce2

80

1(2

7)2

LT:+

,+(3

4,35

)3

MT

:+(3

2)LT

:0,+

(29,

30)

4M

T:0

,0,0

(31,

42,4

3)LT

:0,0

(37,

42)

ST:N

oda

ta.

MT

:Dat

afr

om4

indi

vidu

alst

udie

san

dpo

oled

estim

ate

acro

ss3

stud

ies

(RR

=1.

03,C

I=

0.69

–1.5

1,p

=0.

9)su

gges

tala

ckof

posi

tive

effe

cts.

LT:6

indi

vidu

alst

udie

ssh

owco

nflic

ting

findi

ngs,

pool

edes

timat

eac

ross

2st

udie

s(R

R=

1.22

,0.6

9to

2.15

)su

gges

tsa

smal

land

non-

sig.

effe

ct(p

=0.

50)

favo

ring

usua

lcar

e.O

vera

ll(m

in.f

ollo

w-u

p=

6m

os):

9in

divi

dual

stud

ies

show

confl

ictin

gfin

ding

s,po

oled

estim

ate

acro

ss4

stud

ies

(RR

=1.

03,0

.82

to1.

29)

sugg

ests

noov

eral

leff

ect(

p=

0.8)

,whi

chw

asno

tgre

atly

alte

red

byus

ing

afix

edef

fect

sm

etho

d,od

ds-r

atio

stat

istic

ora

subg

roup

anal

ysis

inth

e3

stud

ies

with

likel

yta

rget

ing.

Sym

ptom

s/as

thm

aco

ntro

l2

71

(35)

1(2

7)1

ST:0

(28)

3ST

:+,+

(0fo

rhi

gher

risk

subg

roup

)(4

0,39

)M

T:+

(31)

3ST

:0,0

(41,

42)

MT

:0,0

(42,

43)

LT:0

(42)

ST:5

indi

vidu

alst

udie

ssh

owco

nflic

ting

findi

ngs.

Pool

edes

timat

eac

ross

2st

udie

sre

port

ing

com

posi

tesy

mpt

omsc

ores

(SM

D=

−0.2

2,−0

.60

to0.

17)

sugg

ests

asm

alla

ndno

n-si

g.ef

fect

(p=

0.27

).M

T:3

indi

vidu

alst

udie

ssh

owco

nflic

ting

findi

ngs.

Pool

edes

timat

eac

ross

2st

udie

sre

port

ing

com

posi

tesy

mpt

omsc

ores

(SM

D=

0.00

,−0.

33to

0.33

)su

gges

tsno

over

alle

ffec

t(p

=0.

99).

LT:O

nly

one

stud

yex

amin

ing

effe

cts.

Ove

rall

(min

.fol

low

up=

1m

o):7

indi

vidu

alst

udie

ssh

owco

nflic

ting

findi

ngs.

Pool

edes

timat

eac

ross

3st

udie

sre

port

ing

com

posi

tesy

mpt

omsc

ores

(SM

D=

−0.0

8,−0

.39

to0.

23)

sugg

ests

asm

alla

ndno

n-si

g.ef

fect

(p=

0.63

)w

hich

was

nota

ltere

dby

use

ofa

fixed

effe

cts

mod

el.S

ubgr

oup

anal

ysis

ofhi

gher

risk

patie

nts

inon

ein

divi

dual

stud

ysu

gges

tsth

atan

ypo

sitiv

eef

fect

son

sym

ptom

sin

thos

ew

ithse

vere

asth

ma

may

note

xten

dto

patie

nts

athi

gher

risk

.(C

onti

nued

onne

xtpa

ge)

235

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

ichi

gan

Uni

vers

ity o

n 10

/31/

14Fo

r pe

rson

al u

se o

nly.

TAB

LE

3.—

Num

bers

ofst

udie

sas

sess

ing

and

repo

rtin

gad

equa

teda

tafo

rdi

ffer

ent

cate

gori

esof

outc

omes

and

synt

hese

sof

findi

ngs

from

thes

ein

shor

t-(S

T),

med

ium

-(M

T)

and

long

-ter

m(L

T)

(whe

re0

=no

nsig

nific

ante

ffec

ts;+

=si

gnifi

cant

effe

cts

ofps

ycho

-edu

catio

nali

nter

vent

ion

com

pare

dto

usua

lcar

e).(

Con

tinu

ed)

No.

ofst

udie

sre

port

ing

asse

ssm

ento

fou

tcom

e

No.

ofst

udie

sno

tre

port

ing

com

para

tive

num

eric

alda

tafo

rou

tcom

e

No.

ofan

dfin

ding

sfr

omst

udie

sre

port

ing

adeq

uate

com

para

tive

num

eric

alou

tcom

eda

tafr

omw

hich

mea

ning

ful

sum

mar

yst

atis

tics

for

met

a-an

alys

isco

uld

notb

eca

lcul

ated

Type

ofou

tcom

eC

OSs

RC

Ts

CO

SsR

CT

sC

OSs

RC

Ts

No.

ofan

dfin

ding

sfr

omR

CT

sre

port

ing

data

suita

ble

for

incl

usio

nin

met

a-an

alys

esR

CT

s

Sum

mar

yfin

ding

s,in

clud

ing

pool

edes

timat

es(R

R/S

MD

,95

%co

nfide

nce

inte

rval

s)fr

omm

eta-

anal

yses

and

any

subg

roup

and

sens

itivi

tyan

alys

esw

here

able

tobe

unde

rtak

en

Hea

lthst

atus

/qua

lity

oflif

e

17

1(3

5)1

(31)

02

ST:0

(42)

MT

:0(4

2)LT

:0,+

(42,

30)

4ST

:0,0

,+(2

7,41

,40)

MT

:0,0

(27,

29)

ST:4

indi

vidu

alst

udie

sm

ainl

ysh

owa

lack

ofpo

sitiv

eef

fect

s,po

oled

estim

ate

acro

ss3

stud

ies

repo

rtin

gov

eral

lsco

res

onas

thm

a-sp

ecifi

cqu

ality

-of-

life

scal

e(S

MD

=0.

64,0

.05

to1.

24,)

sugg

ests

asi

g.ef

fect

(p=

0.03

).M

T:3

indi

vidu

alst

udie

ssh

owa

lack

ofpo

sitiv

eef

fect

s,po

oled

estim

ate

acro

ss2

stud

ies

repo

rtin

gov

eral

lsco

res

onas

thm

a-sp

ecifi

cqu

ality

oflif

esc

ale

(SM

D=

0.08

,−0.

37to

0.52

)su

gges

tsa

smal

land

non-

sig.

effe

ct(p

=0.

74).

LT:2

indi

vidu

alst

udie

ssh

owco

nflic

ting

findi

ngs.

Ove

rall

(min

.fol

low

-up

=8

wks

):6

indi

vidu

alst

udie

ssh

owm

ainl

yno

n-si

g.ef

fect

s,w

ithcl

ear

posi

tive

effe

cts

seen

only

inst

udie

sof

2ps

ycho

soci

alin

terv

entio

nsin

shor

t-te

rm.P

oole

des

timat

eac

ross

4st

udie

sre

port

ing

over

alls

core

son

asth

ma-

spec

ific

qual

ityof

life

scal

e(S

MD

=0.

45,−

0.07

to0.

98)

sugg

ests

asm

alla

ndno

n-si

g.ef

fect

(p=

0.09

)(F

igur

e3)

,whi

chw

asof

bord

erlin

esi

g.w

hen

afix

edef

fect

sm

odel

was

used

(SM

D=

0.36

,0.

00to

0.72

,p=

0.05

).W

hen

stud

ies

wer

edi

vide

din

tosu

bgro

ups

acco

rdin

gto

thei

rde

gree

ofta

rget

ing,

sig.

pool

edef

fect

sac

ross

the

2w

ithlik

ely

targ

etin

g(S

MD

=0.

91,0

.29

to1.

53,

p=

0.00

4)di

dno

text

end

toth

e2

with

defin

iteta

rget

ing

(SM

D=0

.08,

−0.3

7to

0.52

,p

=0.

74).

Psyc

holo

gica

lm

orbi

dity

06

00

01

MT

:0(3

1)5

ST:0

,0,+

,+(2

7,42

,40

,41)

MT

:0,0

,+(2

7,42

,43)

LT:0

(42)

ST:4

indi

vidu

alst

udie

ssh

owco

nflic

ting

findi

ngs,

pool

edes

timat

eac

ross

4st

udie

sre

port

ing

scor

esof

nega

tive

moo

d(S

MD

=−0

.34,

−0.9

2to

0.24

)su

gges

tsa

smal

land

non-

sig.

effe

ct(p

=0.

25).

MT

:4in

divi

dual

stud

ies

mai

nly

sugg

esta

lack

ofpo

sitiv

eef

fect

s,po

oled

estim

ate

acro

ss3

stud

ies

repo

rtin

gsc

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FIGURE 3.—Forest plot showing meta-analysis, divided by asthma subgroups (likely and definite targeting), of standardized mean differences (SMD) calculated fromasthma-specific quality-of-life scores (where higher scores = better quality of life) at latest follow-up reported by studies.

asthma, but high-quality RCTs targeting the most at-risk pa-tients remain limited. Overall, qualitative and quantitativesyntheses provided no clear, consistent evidence of the effec-tiveness of psycho-educational interventions on health out-comes in a range of adults with severe or difficult asthma.Largely positive effects on self-management-related out-comes, statistically significant effects on health outcomesfrom individual studies, and potentially important but non-significant pooled effects on admissions, quality of life, andpsychological morbidity were mainly confined to the short-term. However, many studies were small and likely un-derpowered, and the limited numbers of studies and pa-tients included in meta-analyses resulted in wide confidenceintervals.

Limited subgroup and sensitivity analyses suggest thatpsycho-educational interventions may have important effectson admissions (leading to ∼30% reduction), quality of life,and possibly psychological morbidity in patients with severeasthma or single risk factors alone. However, these effectsdo not appear to extend to patients with multiple factorscomplicating management. Although based on small num-bers of studies, the consistency of this finding across several

FIGURE 4.—Forest plot showing meta-analysis, divided by asthma subgroups (likely and definite targeting), of standardized mean differences (SMD) calculated frompsychological morbidity scores (where higher scores = greater morbidity) at latest follow-up reported by studies.

outcomes where results from different studies were pooled,and observation of a similar failure of effects to extend tohigher-risk patients in two individual studies including sub-group analyses, point to its authenticity. This is also supportedby our review of a larger number of studies in children (26).Owing to the limited number of studies suitable for inclu-sion in meta-analyses, range of interventions assessed, andtendency for more intensive interventions to target more com-plex patients, we were unable to explore the relative effec-tiveness of intervention types.

Strengths and WeaknessesThis review complements and expands on existing sys-

tematic reviews in this field that have suggested that somepsycho-educational interventions for asthma are effective(19–22). We had some success in answering questions re-garding the generalizability of findings from these to the clin-ically and economically important subgroup that accountsfor the majority of morbidity, mortality, and costs associ-ated with asthma. Unlike the only previous review focussedon high-risk patients (23), we undertook wide and thor-ough searching and used explicit definitions and systematic

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methods in selecting, assessing, and synthesizing literature inan attempt to provide a comprehensive and unbiased pictureof the evidence. The criteria that we used to select studiesjudged to have targeted patients who, on the basis of pre-vious literature (3–7,11–17), were considered to be at riskfrom their asthma could be argued to be somewhat arbitrary.However, the criteria were rigorously applied and we were,to some extent, able to assess the impact of the criteria onour conclusions via our subgroup analyses to explore the rel-ative effectiveness of interventions across different patientgroups.

In contrast to some other reviews (19, 21, 22), our crite-ria for selection of relevant interventions were very explicitand, because they were wide, allowed us to examine in detailthe characteristics of a broad range of potentially related in-terventions, and in so doing challenge previous distinctionsmade between educational, self-management, multi-faceted,and some psychosocial programs. The fact that there wereoften greater differences across interventions classified asbeing of the same type than of different types in terms of,for example, their content, delivery, and intensity, can beargued to justify our synthesis of findings across a spec-trum of psycho-educational programmes. Owing to the di-versity of interventions, range of parameters on which theyvaried, and relatively small number of studies that were ableto be included in meta-analyses we were not, however, ableto explore the impact of differences in interventions on ourconclusions.

Having focused on patients who are commonly excludedfrom existing studies, we included a broader range of studydesigns than is common in systematic reviews on the as-sumption that well-conducted COSs might usefully supple-ment data from RCTs in an area where research is limitedand challenging. However, conclusions are little influencedby the COSs since they made a minimal contribution to qual-itative syntheses and did not contribute to quantitative syn-theses due to limited assessment and reporting of outcomes.Even among the RCTs, the generally poor quality of studiesmust also be considered. For example, none reported on, oradequately met, all quality criteria, and less than half (29, 30,38–40, 42) reported on, or adequately met, all criteria withinany one of the dimensions assessed. However, poor reporting,apparent in the frequent failure to provide details of patientflow, baseline group comparability, and statistical analyses,may have masked study quality.

In an attempt to overcome biases, non-English languageand unpublished data sources were originally searched but,in line with recent methodological research (44), we foundthat these ultimately contributed little to initial synthesesof higher-quality research, hence their exclusion from theupdated review reported here. However, at least two RCTswith potential to contribute to the findings have remainedpublished only as abstracts since 2002 and were thus ex-cluded. Furthermore, two very small published RCTs thatwere included reported the most consistently positive find-ings (40,41). This may indicate the potential for publicationbias to have influenced our results. The summaries of resultsare also somewhat dominated by several trials reporting mul-tiple outcomes (31,42,43) and may be influenced by selectivereporting, apparent in numerous studies.

ImplicationsRegarding clinical practice, our results suggest that for

adults with severe asthma or single risk factors associatedwith adverse outcomes, provision of psycho-educational in-terventions may improve self-management, reduce hospitaladmissions, and improve some health outcomes in the shortterm. However, there is currently a lack of evidence to warrantsignificant changes in the care of patients in whom multipleclinical and psychosocial factors complicate management.Since several studies identified continued inadequacies in themedical care that these patients receive, it appears that untilfurther research is available the emphasis should be on op-timization of routine care to address clinical concerns andalso, ideally, acknowledge potential complicating psychoso-cial factors.

In terms of further research, our review highlights oppor-tunities for additional primary and secondary studies to iden-tify key risk factors for severe and difficult asthma, clarifyhow these interact with each other and over time, and de-velop tools to better identify patients susceptible to adverseoutcomes to ensure appropriate targeting of any future inter-ventions. Our review also suggests scope for further work ondeveloping and evaluating psycho-educational interventionsfor at-risk groups. The apparent increasing overlap betweendifferent types of interventions suggest that an alternativeconceptualization of these, in light of the pathways by whichpsychosocial factors and asthma interact (10), may be a nec-essary precursor to this. Given its established effectivenessin general (18) and function as a core component of many ofthe more effective interventions reviewed, self-managementis likely to be a central feature. However, it is increasinglyrecognized that use of formal psycho-educational theoriesand techniques, which appeared to be lacking from the ma-jority of studies reviewed, may be necessary to achieve self-management–related behavioral changes, particularly amongcomplex patients (10). For example, psychosocial conse-quences of living with a severe illness or recurrent exacer-bations (e.g., depression, anxiety) may need to be addressedand patients’ coping improved before attempts at behavioralchange (10). Given the need for provision of optimal medicalcare alongside any psycho-educational interventions, multi-faceted, multi-disciplinary programs addressing the numer-ous factors affecting asthma may be the most promising futureapproach. These might target key issues (e.g., stress manage-ment) in selected patients (e.g., those with high anxiety) oraddress multiple issues and be individualized to needs amongbroader groups of complex patients. Given identified difficul-ties with at-risk patients attending healthcare facilities, inter-ventions tied to opportunistic contacts in emergency, primarycare, or community settings may also be desirable. The devel-opment of future interventions might also usefully be guidedby reference to the wider range of programs identified in ouroriginal review that have not been evaluated via controlledstudies (26).

Although several studies reviewed mentioned difficultiesin conducting high-quality research in the groups targeted,most demonstrated some success in recruiting and followingup at-risk patients. It thus appears feasible to conduct fur-ther well-designed, pragmatic RCTs of psycho-educationalinterventions in at-risk groups to assess their relative

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effectiveness and ideally cost-effectiveness given potentiallyhigh costs and lack of current data on this topic (26). Thesemight address remaining unanswered questions regarding thekey components, most effective settings, delivery methods,and timing of interventions (e.g., whether scheduled to followacute events). Adequate reporting of these is also essential toallow ongoing evidence syntheses to further inform futureresearch and practice.

CONCLUSION

There is some evidence to suggest that psycho-educationalinterventions can reduce admissions, improve quality of life,and possibly reduce psychological morbidity in patients withsevere asthma or single characteristics associated with dif-ficult asthma. However, effects appear to be mainly shortterm and do not appear to extend to the most at-risk patientsin whom multiple factors complicate management. There isthus a need for further research in these groups before changesare made to the standard care for these patients.

ACKNOWLEDGMENT

The authors would like to acknowledge the contributionof Bridget Candy, Janet Moore, and Nick Healey who pro-vided research and administrative assistance for the initialreview, and Prof. Ian Harvey, Dr. Maria Koutantji, and Dr.Chris Upton who sat on the original project advisory teamand provided methodological, psychological, and clinical ad-vice, respectively. The authors would also like to thank JulieGlanville and Prof. Jos Kliejnen from the NHS Centre forReviews & Dissemination for assistance with searching andmethodological advice, University of East Anglia health li-brarian William Jones, overseas students who acted as trans-lators, authors who responded to requests for information,and referees who provided feedback on the original reviewreport.

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