Table 1.
Characteristics of included studies and key implementation and health outcomes
| Study, year, country, design, risk of bias, duration | Setting, participants recruited | Brief intervention description, control | Key results BOLD are significant results * indicate the trial’s defined primary outcomes |
|---|---|---|---|
| Studies which evaluated the PACE programme | |||
| Bruzzese et al.17 2006 USA 2-group cluster RCT Unclear RoB 2 yr |
44 schools = clusters PCPs: NR 591 low-income ethnic minority families (307 I, 284 C) |
PACE initiative: develops skills for treating asthma, including supporting patients & families to self-manage Incentives: CME credits and catered meals; Invitation letter signed by Commissioner of Health Control: Standard care |
Implementation outcome: NR Health outcome: Compared to control, at 2 yrs difference in patient reported (Mean/yr (SD): • Urgent physician visits: I: 1.7 (3.0), C: 1.8 (3.6) p = NS • ED visits: I: 0.9 (2.2), C: 0.9 (1.8) p = NS • Hospitalisations: I: 0.2 (0.6), C: 0.1 (0.3) p < .05 (favours C) Similar results at 1 yr |
| Cabana et al.18,19 2006 USA 2-group cluster RCT Unclear RoB 2 yr |
10 cities/ regions = clusters PC paediatricians practice: 94 (51 I, 43 C) Children/parents: 870 (418 I; 452 C) |
PACE initiative: develops skills for treating asthma, including supporting patients & families to self-manage Incentives: CME credits, certificate, honorarium Control: Standard care (but received honorarium) |
Implementation outcome: NR Health outcome: Compared to control, at 1 yr difference in change in patient reported (Mean change): • Urgent office visits: 1 yr: I: −1.07, C: −0.9, p = NS; • ED visits: I: −0.55, C: −0.30, p < .05 (sustained at 2 yr, p < 0.038) • Hospitalisations: I: −0.06, C: −0.06, p = NS |
| Clark et al.16,20,21 1998 USA 2-group RCT Unclear RoB 2 yr |
74 practices Paediatricians: 74 (38 I, 36 C) Children/parents: 637 (336 I, 301 C) |
PACE initiative: develops skills for treating asthma, including supporting patients & families to self-manage Control: Standard care |
Implementation outcome: Compared to control: • At 22 m more parents had written plan I: 26%, C: 16%, OR 1.74, p = .03 • At 5 m more physicians gave written plan I: 4.30, C: 3.46, p = 0.001; • Health outcome: Compared to control, at 2 yr there was (Mean): • No difference in patient reported ED visits: I: 0.29, C: 0.47, p = 0.44 • Fewer patient reported hospitalisations: I 0.03, C 0.10, p = 0.03 |
| Griffiths et al.25 2016 UK 2-group cluster RCT Unclear RoB 1 yr |
84 PCPs = clusters Nurses & GPs: NR South Asian adults/children: 375 (183 I, 192 C) |
PACE initiative adapted for UK clinicians caring for South Asian patients: develops skills for treating asthma, including supporting patients & families to self-manage. Two lunchtime seminars Control: Standard care |
Implementation outcome: NR Health outcome: Compared to control, at 1 yr no difference in: * Unscheduled care: OR 0.71 (95% CI 0.43 to 1.20), p = .20 * Time to first unscheduled care: HR 1.19 (95% CI 0.92 to 1.53) p = 0.19 Compared to control, at 3 m there was greater improvement in • QoL (AQ20) mean diff −2.56 (95% CI −3.89 to −1.24), p < 0.001 |
| Shah et al.28 2011 Australia 2-group RCT Unclear RoB 1 yr |
109 PCPs GPs: 150 (78 I, 72 C) Children/parents: 221 (111 I, 110 C) |
PACE initiative: adapted for Australian Cycle of Care develops skills for treating asthma, including supporting patients & families to self-manage Control: Standard care |
Implementation outcome: Compared to control, at 1 yr more: • Parents had a written action plan I: 61% C: 46% diff 15% (95% CI 2 to 28%) p = 0.046 • GPs provided written action plan > 70% of the time I: 76% C: 53% diff 23% (95% CI 11 to 36%) p = 0.002 Health outcome: Compared to control, at 1 yr there was no difference in: • Hospitalization: I: 18% C: 12% diff 6% (95% CI −4 to 15%) p = 0.12 |
| Studies which evaluated initiatives other than PACE | |||
| Cleland et al.22 2007 UK 2-group cluster RCT Unclear RoB 6 months |
13 PCPs = clusters (6 I, 7 C) Nurses: NR Adults: routine data: 629 373 I; 256 C questionnaire: 236 (130 I, 106 C) |
One interactive seminar on effective communication, self-management education, and use of action plans Control: Standard care |
Implementation outcome: NR Health outcome: Compared to control, at 6 m there was no difference in: • Steroid courses: I: 1.07 (1.04–1.10) C: 1.11 (1.07–1.45) p = 0.12 • Compared to control, at 6 m there was: * Improved QoL (miniAQLQ) I: 6.49 (6.40–6.59) C: 6.33 (6.23–6.44) p = 0.03 • No difference in asthma control (ACQ): I: 3.14 (3.06–3.23) C: 3.2 (3.10–3.30) p = 0.43 |
| Cohen et al.23 2014 Israel 5-group CCT High RoB 2 yrs |
PCPs in 5 HMO divisions = ‘clusters’ GPs: 258 (45 I1, 35 I2, 21 I3, 36 I4, 121 C) Nurses: NR Patients > 12 yr: 1056 (54 I1, 219 I2, 106 I3, 171 I4, 506 C) |
Focused on effective communication, self-management education for patient/families, and use of action plans I1: GPs: Patients with uncontrolled asthma identified & targeted I2: GPs: I1 plus workshop I3: GPs & nurses: I1 plus simulation training I4: GPs & nurses: I1 plus I2 plus I3 Control: Standard care |
Implementation outcome: NR Health outcome: Change in rate of uncontrolled asthma (based on inhaler purchase data) 1 yr-baseline I1: 0.15 I2: 0.14 I3: 0.20 I4: 0.28 C: 0.003 • Diff I1-C: 0.15 z-score 3.27 p < 0.01 • Diff I2-C: 0.13 z-score 5.67 p < 0.01 • Diff I3-C: 0.19 z-score 5.00 p < 0.01 • Diff I4-C: 0.26 z-score 7.97 p < 0.01 Similar results at 2 yrs |
| Evans et al.24 1997 USA 2-group cluster RCT Unclear RoB 2 yr |
Clusters = 2 panels of PCPs (11 I, 11 C) Professionals: 134 (80 I, 54 C) Children/parents: 358 |
Creating a Medical Home for Asthma; Focused on effective communication, self-management education for patient/families, and use of action plans Control Standard care (but received guidelines) |
Implementation outcome: Compared to control, at 2 yr there was: • no difference in the proportion of patients given written plan by physician: I: 78% C: 76% (p = NS) or nurse I: 60% C: 53% p = NS • increased proportion received education by physician I: 71% C: 58% p < 0.01 but no difference by nurse I: 61% C: 44% p = NS Health outcome: No difference in proportion who received oral steroid course I: 5% C: 1% p = NS Difference in proportion who received • any β-agonist I: 74% C: 52% p < .05 • any inhaled anti-inflammatory I: 25% C: 2% p < .001 |
| Homer et al.26 2005 USA 2-group cluster RCT High RoB 1 yr |
43 practices = clusters (22 I, 21 C) 3-member team (physician, nurse, office staff): NR Children/parents: 631 (294 I, 337 C) |
Learning collaborative project: participants identified performance gaps in their own practices’ asthma care, and learning was based on these Control: Standard care |
Implementation outcome: Compared to control, at 1 yr there was no difference in: * proportion of patients given written management plan: I: 54% C: 41% p = NS Health outcome: Compared to control, at 1 yr there was no difference in: • Hospitalisation: I: 2% C: 4% p = NS • ED visit: I: 17% C: 22% p = NS • Asthma attack: I: 40% C: 36% p = NS |
| Prabhakaran et al.27 2012 Singapore 3-group RCT Unclear RoB 3 months |
1 tertiary hospital Enroled nurses: 162 (59 I1, 55 I2, 48 I3) No patients recruited |
Education on general management of asthma, specifically including self-management support I1: Workshop with practical skills I2: As I1 except lectures in e-learning format I3: combination of I1 and I2 Control: Interventions compared, no standard care control |
Implementation outcome: Knowledge (not assessed with validated tool) Health outcomes: NR |
| Sheikh et al.29 2016 USA 2-group cluster RCT Unclear RoB 2 yr |
10 PC paediatric practices = clusters (5 I, 5 C) Professionals: NR Patients: routine data: NR |
Education of Asthma Leaders in each practice on general management of asthma, specifically including self-management support Control: delayed intervention |
Implementation outcome: Compared to control, at 1 yr there was increased recording of: • Asthma education: I: 56.1%, C: 19.5%, p ≤ 0.05 • Asthma action plan: I: 29%, C: 5.4%, p ≤ 0.05 Compared to control, at 1 yr there was no difference in: • Acute care visit: I: 90.3%, C: 91.9%, NS |
| Smeele et al.30 1999 Netherlands 2-group cluster RCT Unclear RoB 1 yr |
PCPs in same ‘local group’ = cluster GPs: 34 practice assistants: NR Adult asthma or COPD patients: 544 |
Education covered general management of asthma (and COPD), specifically including self-management support Control: Standard care |
Implementation outcome: Compared to control, at 1 yr there was no difference in change in proportion: • Patients receiving written education I: +3% C: +7% Diff −1% (−13 to 11%) p = 0.8 Health outcome: Compared to control, at 1 yr there was no difference in: • patients reporting exacerbations past 3 months (ratio) I: 0 C: −0.11 p = 0.1 |
| Toelle et al.31 1993 Australia 2-group CCT High RoB 9 months |
Primary schools in 2 areas = ‘clusters’ HCPs: NR Children/families: 132 (72 I, 60 C) |
Evening workshops and in-service education on effective communication, self-management education for patient/families, and use of action plans Control: Standard care |
Implementation outcome: NR Health outcome: Compared to control, at 6 m there was no difference in: • Unscheduled doctor/ ED visits, mean (95% CI) I: 1.51 (0.94 to 2.08) C: 1.67 (1.01 to 2.33) p = NS • Symptoms limiting activity, % (95% CI) I: 18.60% (7.0% to 30.2%) C: 8.30% (0% to 17.3%) p = NS |
| Tomson et al.32 1997 Sweden 2-group CCT High RoB 18 months |
2 localities = ’clusters’ 30 PCPs (21 I, 9 C) GPs: NR Patients: 331 (249 I, 82 C) |
Academic detailing for diagnosis and treatment of asthma, covering general management of asthma, specifically including self-management support Control: Standard care |
Implementation outcome: Compared to control, at 1 yr there was no difference in proportion: • Given a PEF-based self-management plan I: 46% C: 32% p = 0.05 Health outcome: Compared to control, at 1 yr there was no difference in ratios of prescribed inhaled β-agonists to inhaled glucocorticoids measured as defined daily doses: p = NS for areas/’clusters’ |
| Volovitz et al.33 2003 Israel 4-group CCT High RoB 9 months |
PCPs in two regions within a HMO GPs & paediatricians: NR Adults & children: NR |
Education covered general management of asthma, specifically including self-management support I1: Asthma education programme; application of learning to future consultations monitored I2: I1 except follow-up not monitored Control 1: Standard care, patients in same region Control 2: Standard care, patients in different region |
Implementation outcome: data NR in full so not extracted Health outcome: Compared to control, at 9 m patient reported: • Improvement in shortness of breath I1: 64% I2: 39% p > 0.005 (significant) |
ACQ, Asthma control questionnaire, AQ20, Airways Questionnaire 20, AQLQ, Asthma Quality of Life Questionnaire, CCT, controlled clinical trial; C, control group, CME, continuing medical education; COPD, chronic obstructive pulmonary disease, ED, emergency department, GP, general practitioner, HMO, health maintenance organization, I, intervention group, NR, not reported, PACE, Physician Asthma Care Education, PCP, primary care physician, PEF, peak expiratory flow, QoL, quality of life, RCT, randomised controlled trial, RoB, risk of bias