NIHR Signal Asthma self-management programmes can reduce unscheduled care

Published on 20 June 2017

People with asthma who receive supported self-management are less likely to attend A&E or be admitted to hospital. The interventions are unlikely to increase overall costs for healthcare services. Those who self-manage are also likely to have more controlled asthma and a better quality of life.

This extensive overview of systematic reviews included evidence from 270 randomised controlled trials exploring the effects of asthma self-management on healthcare utilisation and costs. Self-management programmes were slightly more expensive, but this cost was likely to be offset by reducing unplanned medical visits and improving patient quality of life.  

Trials covered different self-care education programmes delivered in a range of contexts. However, programmes which included written action plans supported by regular professional review were found to be most beneficial.

These findings are in keeping with current guideline recommendations and emphasise that supported self-management programmes for asthma should be prioritised.

Asthma self-management programmes can reduce unscheduled care

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Why was this study needed?

Asthma is a common long-term condition which causes wheezing and shortness of breath. In the UK, 185 people are admitted to hospital every day because of asthma attacks. Treating asthma costs the NHS about £1 billion per year.

Current guidelines recommend self-management programmes for people with asthma, which centre on education and written personalised asthma action plans. This is most effective when it’s supported through regular reviews with a professional.

Self-management programmes aren’t always delivered effectively. The 2014 UK National Review of asthma deaths found that self-management training was only reported for 23%.

This large systematic overview aimed to gather the available evidence on supported self-management for asthma, from systematic reviews and recent trials. The reviewers focused on how self-management might affect asthma control and the use of healthcare resources.

What did this study do?

This meta-review, or overview, included 270 randomised controlled trials in 27 systematic reviews alongside later randomised trials.

The studies were identified by two large reviews commissioned to provide an overview of self-supported management in asthma: the Practical Systematic Review of Self-Management Support (PRISMS) and the Reducing Care Utilisation through Self-Management Interventions (RECURSIVE) health economic review.  

Self-management was defined as giving someone “confidence to deal with medical management, role management and emotional management of their condition.” The main outcome of the PRISMS review was unplanned use of healthcare services, and for the RECRUSIVE review it was costs and cost effectiveness.

Trials came from 29 middle- to high-income countries and were published between 1979 and 2015. Most trials were of 12 months duration. Interventions and target population (for example, children or minority groups) varied across studies.

What did it find?

  • Six moderate to high quality reviews found that supported self-management reduced hospital admissions, with relative risks ranging from 0.50 to 0.79 compared to the control group. This suggests that admissions could be reduced by about one quarter to a half. Another six reviews, of variable quality, found inconsistent effects.
  • Four moderate to high quality reviews found a reduction in A&E attendances, with significant relative risks ranging from 0.73 to 0.82. Four narrative reviews found an effect in at least half of their trials, one review showed inconsistent results and one showed no benefit.
  • Three high quality reviews found that people receiving supported self-management had fewer unscheduled consultations, with relative risks of around 0.68. Three moderate quality reviews found an effect in at least half of their trials, while two poor quality reviews had inconsistent results.
  • Looking at target groups and healthcare contexts, some reviews found a benefit of culture-specific programmes and those targeting children. Interventions involving education, action plans and regular professional review were most beneficial.
  • The RECURSIVE economic review (24 trials, 7061 participants) showed that self-management was more costly than usual care. The researchers report that the cost is likely to be offset by savings from reduced healthcare utilisation and conclude that overall it does not lead to significant increases in total healthcare costs.

What does current guidance say on this issue?

Guidelines from the British Thoracic Society and the Scottish Intercollegiate Guidelines Network advise that everyone with asthma should receive supported self-management in the form of a written personalised action plan that is regularly reviewed by a health professional. 

The guidelines emphasise that every asthma consultation, in both primary and secondary care, gives an opportunity to review and reinforce the person’s education and understanding. Brief simple education linked to patient goals is most likely to be acceptable to patients. Culturally appropriate materials should be available for ethnic minority groups.

NICE is currently preparing guidelines on the management of asthma.

What are the implications?

Asthma self-management support is already recommended in the UK. This comprehensive body of evidence reinforces current guidance to prioritise the provision of programmes supported by regular professional review.

People with asthma, as with other long-term conditions, can be empowered by learning to manage their condition confidently. This can ease the burden on the NHS by reducing the number of unplanned visits to healthcare services.

Further clarity on the optimal components of self-management support for different population groups would be beneficial. Studies with longer follow up might confirm long-term sustainability of self-management interventions in asthma.

Citation and Funding

Pinnock H, Parke HL, Panagioti M, et al; PRISMS and RECURSIVE groups. Systematic meta-review of supported self-management for asthma: a healthcare perspective. BMC Med. 2017;15(1):64.

This project was funded by the National Institute for Health Research [Health Services and Delivery Research Programme] (project numbers 11/1014/04 and 11/1014/06).

Bibliography

Asthma UK. Asthma facts and statistics. London: Asthma UK; 2017.

BTS / SIGN. British guideline on the management of asthma: A national clinical guideline. London. British Thoracic Society / Scottish Intercollegiate Guidelines Network; 2016.

NICE. Asthma Management. London: National Institute for Health and Care Excellence; 2015.

Panagioti M, Richardson G, Murray E, et al. Reducing care utilisation through self-management interventions (RECURSIVE): a systematic review and meta-analysis. Health Serv Deliv Res. 2014;2:54.

Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: Royal College of Physicians; 2014.

Taylor SJC, Pinnock H, Epiphaniou E et al. A rapid synthesis of the evidence on interventions supporting self-management for people with long- term conditions. (PRISMS Practical Systematic Review of Self-Management Support for long-term conditions). Health Serv Deliv Res. 2014;2:54.

Why was this study needed?

Asthma is a common long-term condition which causes wheezing and shortness of breath. In the UK, 185 people are admitted to hospital every day because of asthma attacks. Treating asthma costs the NHS about £1 billion per year.

Current guidelines recommend self-management programmes for people with asthma, which centre on education and written personalised asthma action plans. This is most effective when it’s supported through regular reviews with a professional.

Self-management programmes aren’t always delivered effectively. The 2014 UK National Review of asthma deaths found that self-management training was only reported for 23%.

This large systematic overview aimed to gather the available evidence on supported self-management for asthma, from systematic reviews and recent trials. The reviewers focused on how self-management might affect asthma control and the use of healthcare resources.

What did this study do?

This meta-review, or overview, included 270 randomised controlled trials in 27 systematic reviews alongside later randomised trials.

The studies were identified by two large reviews commissioned to provide an overview of self-supported management in asthma: the Practical Systematic Review of Self-Management Support (PRISMS) and the Reducing Care Utilisation through Self-Management Interventions (RECURSIVE) health economic review.  

Self-management was defined as giving someone “confidence to deal with medical management, role management and emotional management of their condition.” The main outcome of the PRISMS review was unplanned use of healthcare services, and for the RECRUSIVE review it was costs and cost effectiveness.

Trials came from 29 middle- to high-income countries and were published between 1979 and 2015. Most trials were of 12 months duration. Interventions and target population (for example, children or minority groups) varied across studies.

What did it find?

  • Six moderate to high quality reviews found that supported self-management reduced hospital admissions, with relative risks ranging from 0.50 to 0.79 compared to the control group. This suggests that admissions could be reduced by about one quarter to a half. Another six reviews, of variable quality, found inconsistent effects.
  • Four moderate to high quality reviews found a reduction in A&E attendances, with significant relative risks ranging from 0.73 to 0.82. Four narrative reviews found an effect in at least half of their trials, one review showed inconsistent results and one showed no benefit.
  • Three high quality reviews found that people receiving supported self-management had fewer unscheduled consultations, with relative risks of around 0.68. Three moderate quality reviews found an effect in at least half of their trials, while two poor quality reviews had inconsistent results.
  • Looking at target groups and healthcare contexts, some reviews found a benefit of culture-specific programmes and those targeting children. Interventions involving education, action plans and regular professional review were most beneficial.
  • The RECURSIVE economic review (24 trials, 7061 participants) showed that self-management was more costly than usual care. The researchers report that the cost is likely to be offset by savings from reduced healthcare utilisation and conclude that overall it does not lead to significant increases in total healthcare costs.

What does current guidance say on this issue?

Guidelines from the British Thoracic Society and the Scottish Intercollegiate Guidelines Network advise that everyone with asthma should receive supported self-management in the form of a written personalised action plan that is regularly reviewed by a health professional. 

The guidelines emphasise that every asthma consultation, in both primary and secondary care, gives an opportunity to review and reinforce the person’s education and understanding. Brief simple education linked to patient goals is most likely to be acceptable to patients. Culturally appropriate materials should be available for ethnic minority groups.

NICE is currently preparing guidelines on the management of asthma.

What are the implications?

Asthma self-management support is already recommended in the UK. This comprehensive body of evidence reinforces current guidance to prioritise the provision of programmes supported by regular professional review.

People with asthma, as with other long-term conditions, can be empowered by learning to manage their condition confidently. This can ease the burden on the NHS by reducing the number of unplanned visits to healthcare services.

Further clarity on the optimal components of self-management support for different population groups would be beneficial. Studies with longer follow up might confirm long-term sustainability of self-management interventions in asthma.

Citation and Funding

Pinnock H, Parke HL, Panagioti M, et al; PRISMS and RECURSIVE groups. Systematic meta-review of supported self-management for asthma: a healthcare perspective. BMC Med. 2017;15(1):64.

This project was funded by the National Institute for Health Research [Health Services and Delivery Research Programme] (project numbers 11/1014/04 and 11/1014/06).

Bibliography

Asthma UK. Asthma facts and statistics. London: Asthma UK; 2017.

BTS / SIGN. British guideline on the management of asthma: A national clinical guideline. London. British Thoracic Society / Scottish Intercollegiate Guidelines Network; 2016.

NICE. Asthma Management. London: National Institute for Health and Care Excellence; 2015.

Panagioti M, Richardson G, Murray E, et al. Reducing care utilisation through self-management interventions (RECURSIVE): a systematic review and meta-analysis. Health Serv Deliv Res. 2014;2:54.

Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: Royal College of Physicians; 2014.

Taylor SJC, Pinnock H, Epiphaniou E et al. A rapid synthesis of the evidence on interventions supporting self-management for people with long- term conditions. (PRISMS Practical Systematic Review of Self-Management Support for long-term conditions). Health Serv Deliv Res. 2014;2:54.

Systematic meta-review of supported self-management for asthma: a healthcare perspective

Published on 17 March 2017

Pinnock,H, Parke HL, Panagioti M, Daines L, Pearce G, Epiphanour E, Bower P, Sheikh A, Griffiths J, Taylor SJC.

BMC Medicine , 2017

Background Supported self-management has been recommended by asthma guidelines for three decades; improving current suboptimal implementation will require commitment from professionals, patients and healthcare organisations. The Practical Systematic Review of Self-Management Support (PRISMS) meta-review and Reducing Care Utilisation through Self-management Interventions (RECURSIVE) health economic review were commissioned to provide a systematic overview of supported self-management to inform implementation. We sought to investigate if supported asthma self-management reduces use of healthcare resources and improves asthma control; for which target groups it works; and which components and contextual factors contribute to effectiveness. Finally, we investigated the costs to healthcare services of providing supported self-management. Methods We undertook a meta-review (systematic overview) of systematic reviews updated with randomised controlled trials (RCTs) published since the review search dates, and health economic meta-analysis of RCTs. Twelve electronic databases were searched in 2012 (updated in 2015; pre-publication update January 2017) for systematic reviews reporting RCTs (and update RCTs) evaluating supported asthma self-management. We assessed the quality of included studies and undertook a meta-analysis and narrative synthesis. Results A total of 27 systematic reviews (n = 244 RCTs) and 13 update RCTs revealed that supported self-management can reduce hospitalisations, accident and emergency attendances and unscheduled consultations, and improve markers of control and quality of life for people with asthma across a range of cultural, demographic and healthcare settings. Core components are patient education, provision of an action plan and regular professional review. Self-management is most effective when delivered in the context of proactive long-term condition management. The total cost (n = 24 RCTs) of providing self-management support is offset by a reduction in hospitalisations and accident and emergency visits (standard mean difference 0.13, 95% confidence interval −0.09 to 0.34). Conclusions Evidence from a total of 270 RCTs confirms that supported self-management for asthma can reduce unscheduled care and improve asthma control, can be delivered effectively for diverse demographic and cultural groups, is applicable in a broad range of clinical settings, and does not significantly increase total healthcare costs. Informed by this comprehensive synthesis of the literature, clinicians, patient-interest groups, policy-makers and providers of healthcare services should prioritise provision of supported self-management for people with asthma as a core component of routine care.

Expert commentary

This "review of reviews" confirms that supporting patients to self-manage their asthma (through education about compliance, recognition of disease deterioration, provision of an action plan and reinforcement by regular review) reduces unscheduled attendance and improves quality of life, and thereby pays for itself.

It works best when delivered in familiar surroundings in a targeted fashion according to the lifestyle, fears and prejudices of the recipient by health professionals (and not impassively by leaflets or video clips) and helps everyone regardless of culture and healthcare setting. An aspect of asthma care which is absolutely not to be ignored.

Christopher Corrigan, Professor of Asthma, Allergy and Immunology, King’s College London