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

1Asthma is common, affecting 334 million people worldwide, and is responsible for substantial morbidity and an increasing burden on healthcare services globally. In the UK, there are over 6 million primary care consultations, and 100,000 hospital admissions each year, at an estimated cost of £1 billion per year.

2For a quarter of a century, national and international guidelines have recommended – unequivocally – that people with asthma should be provided with self-management education reinforced by a personalised asthma action plan and supported by regular review, though mode of delivery, personnel delivering the support, the targeted group and the intensity of the intervention vary. The 2014 UK National Review of Asthma Deaths provided a stark reminder of the importance of ensuring that people with asthma respond in a timely and appropriate manner to deteriorating symptoms: only 23% had documented evidence of having been provided with self-management education and 45% of people who died had not sought or received medical attention in their final attack.

3However, despite self-management being highlighted as a core component of all models of care for people with long-term conditions (LTCs) and the concept being well established in the context of asthma, in practice only a minority of people with asthma have an action plan. Effective implementation requires a whole systems approach, combining active engagement of patients with the training and motivation of professionals embedded within an organisation in which self-management is valued. Patient organisations, healthcare professionals, policy-makers, commissioners and providers of healthcare services thus need an up-to-date systematic overview of the evidence to inform decisions about prioritisation of supported self-management and to underpin implementation strategies within diverse healthcare systems.

4The data presented in this paper are derived from two parallel programmes of work on supported self-management in LTCs commissioned by the National Institute of Health Research: Practical Systematic Review of Self-Management Support (PRISMS) and Reducing Care Utilisation through Self-management Interventions (RECURSIVE). In the context of asthma, we aimed to answer questions of importance to clinicians, patient-interest groups, managers responsible for developing healthcare services and policy-makers: can supported self-management reduce the use of healthcare resources and improve asthma control? More specifically, in which target groups has it been shown to work, which components are important, in what healthcare contexts, and at what cost?

5We used established methodology for undertaking a meta-review of systematic reviews (PRISMS) and a systematic review of randomised controlled trials (RCTs) (RECURSIVE). The PRISMS and RECURSIVE reviews were undertaken during 2012–2013 with initial searches completed in November 2012 and May 2012, respectively. We updated the PRISMS searches in March 2015 with a pre-publication update in January 2017, and the RECURSIVE searches in September 2015. RECURSIVE is registered on PROSPERO: CRD42012002694. (PRISMS could not be registered because PROSPERO does not register meta-reviews.)

6Table 1 summarises the PICOS criteria, search strategies, sources and search dates; further details are in Additional file 1. The PRISMS search strategy involved searching nine electronic databases using the terms: ‘self-management support’ AND ‘asthma’ AND ‘systematic review’. We defined self-management as ‘the tasks that individuals must undertake to live with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management and emotional management of their conditions’. For the update, we searched not only for systematic reviews published after our initial search date but also for RCTs published after the search dates used by the included systematic reviews (see Additional file 2 for the details of these dates). Included systematic reviews were grouped according to the populations studied (children, adults or ethnic minority groups) and the search dates of the reviews extracted. Dates for the update RCT search were set from the date of the latest review search within each population group.

7The RECURSIVE search strategy in nine databases comprised the terms: ‘self-management support’ AND ‘long-term condition’ AND ‘healthcare use’ AND ‘randomised controlled trial’. (RECURSIVE included asthma and other LTCs in a single search.) We also specifically sought health economic publications linked to included RCTs.

8Table 2 summarises the PRISMS and RECURSIVE processes. Following training (repeated cycles of duplicate screening of 100 titles, team discussion and clarification of exclusion rules), one reviewer (HLP or GP for PRISMS; LD for the update; MP for RECURSIVE) reviewed titles and abstracts and selected possibly relevant studies. A random sample of titles and abstracts (10% in PRISMS; 40% in RECURSIVE) was examined by a second reviewer (HP for PRISMS; PB or NS for RECURSIVE) working independently as a quality check. The agreement was 97% for the initial search and 99% for the update in PRISMS and 87% for the initial search and 88% for the update in RECURSIVE.

9After a similar training process, the full texts of all potentially eligible studies were assessed against the eligibility criteria (see Additional file 3) by one reviewer (HLP for PRISMS; LD for update; MP for RECURSIVE). Second reviewers undertook a 10% check for PRISMS (HP) and a 30% check for RECURSIVE (PB or NS), achieving 83% and 85% agreement, respectively. Disagreements were because unclear papers were included by the reviewer pending discussion with a lead investigator. Uncertainties and disagreements were resolved by full team discussion.

10We used the R-AMSTAR (Revised Assessment of Multiple Systematic Reviews) quality appraisal tool to assess the methodological quality of the systematic reviews included in the PRISMS study. This reflects both the quality of the review process and the rigour with which the review assessed the quality of the studies it included. We used the Cochrane Risk of Bias tool to assess the quality of RCTs included in the updated search. Quality assessment was undertaken by HLP or LD and independently by a second reviewer (HP) with disagreements resolved by discussion within the team (EE, GP, HLP, ST and HP).

11To reflect both quality and size of the review, we developed a star weighting system based on (a) the R-AMSTAR score (≥31 was defined as ‘high-quality’) and (b) the number of participants (≥1000 participants was defined as ‘large’):*** Large high-quality review** Either small high-quality review or large low-quality review* Small low-quality review

12*** Large high-quality review

13** Either small high-quality review or large low-quality review

14* Small low-quality review

15In the RECURSIVE study, quality assessment of formal economic evaluations was undertaken using the Drummond checklist; RCTs reporting healthcare utilisation were assessed by judging allocation concealment (the quality component most associated with treatment effect) as adequate or inadequate according to the Cochrane Risk of Bias tool.

16The primary outcome in the PRISMS meta-review was unscheduled use of healthcare resources (specifically unscheduled consultations, accident and emergency (A&E) department attendances and hospital admissions). Other outcomes of interest were asthma control, asthma-related quality of life and process outcomes (specifically, ownership of action plans). Healthcare utilisation rates and costs were the primary focus of the RECURSIVE review, especially major cost drivers (i.e. hospitalisation rates and costs) and comprehensive summaries including multiple sources of cost. The results of formal cost-effectiveness, cost-utility and cost–benefit analyses were also of interest.

17Data for the PRISMS review were extracted by HLP and LD (update) using a piloted data extraction form, and checked independently by HP for integrity and accuracy. Disagreements were resolved by team discussion. We extracted data on review rationale, the self-management intervention under review, review methodology, summary details of included RCTs (participant demographics, comparison groups, settings, service arrangements, components, duration/intensity of the intervention, follow-up arrangements) and the results of meta-analyses and narrative syntheses. We extracted the findings and conclusions as synthesised by the authors of the systematic reviews, specifically avoiding going back to the individual primary studies. The RCTs in the update review were extracted using similar headings.

18A piloted data extraction sheet was devised for RECURSIVE that included descriptive data (characteristics of studies, populations and interventions) and quantitative data (for use in meta-analyses). All the descriptive data and approximately 40% of the quantitative data were double-extracted by two members of the research team working independently.

19Meta-analysis is inappropriate at the meta-review level owing to the overlap of included RCTs between reviews. However, for the primary outcome, where two or more systematic reviews (including the RECURSIVE meta-analyses) present pooled statistics, we displayed the results graphically by creating ‘meta-Forest plots’. We undertook narrative syntheses to answer our key questions: Does supported self-management reduce use of healthcare resources and improve asthma control? For which target groups does it work? Which components contribute to effectiveness? and In what contexts does supported self-management work? We categorised the reviews and RCTs included in the PRISMS meta-review according to the question(s) that they answered (see Tables 3 and 4: column 3) and synthesised the findings within these categories.

20The final question (What is the effect of self-management on healthcare utilisation and costs?) was answered by a meta-analysis of the RECURSIVE RCT data. The primary analysis explored whether self-management support could reduce utilisation without compromising outcomes. Standardised mean differences (SMD) were computed using a random effects model meta-analysis due to anticipated heterogeneity. Four meta-analyses examined the effects of self-management support interventions on hospitalisation rates, A&E attendances, quality of life and total costs, respectively. We then constructed permutation plots of the data from the subset of trials reporting both utilisation (hospitalisation rates, A&E attendances or total costs) and health outcomes (quality of life). Further details about the analytic approach are described in the RECURSIVE report. Forest plots and permutation plots for the subset of studies reporting both health outcomes and utilisation outcomes were constructed in STATA version 14.

21The PRISMS and RECURSIVE teams worked independently, but held regular teleconferences to enable synergies between the findings of the parallel reviews to be developed. Frequent meetings of the multidisciplinary teams aided interpretation of the emerging findings. Finally, we held an end-of-project stakeholder conference at which the findings and over-arching conclusions from PRISMS and RECURSIVE were presented to 34 multidisciplinary stakeholders, including people with LTCs, clinicians, commissioners, providers of healthcare services and policy-makers. Small discussion groups discussed and advised on practical implications for commissioning and providing services for people with LTCs.

22The PRISMS project (which reviewed evidence from 14 LTCs) benefited from a lay collaborator who was involved from the inception of the project. She and other lay representatives from a range of LTC interest groups (including Asthma UK) contributed to an initial stakeholder workshop at which the choice of LTCs studied in the project and self-management interventions of interest were discussed. Lay members also participated in the end-of-project workshop (described above), which aided interpretation and guided dissemination. The PRIMER patient and public involvement group at the University of Manchester, UK, collaborated with the RECURSIVE project.

23We updated our PRISMS searches in January 2017 by undertaking forward citation of the original included reviews using Web of Science. Forward citation has been shown to be an efficient and effective method of identifying relevant papers in systematic reviews of complex and heterogeneous evidence. We considered it was very unlikely that a subsequent systematic review or RCT would be published without citing at least one of the previously published reviews. One reviewer (HP) undertook focused data extraction of key findings, which were checked by MP. The additional data were added into the syntheses as appropriate. Had we identified studies that substantially changed our conclusions we planned to undertake full duplicate data extraction, quality assessment and revise our synthesis.

24Figure 1 illustrates the PRISMA flow chart for both reviews. After removal of duplicates, 9633 references were identified from the initial PRISMS search and an additional 6321 from the update search. From these, 25 systematic reviews were included in the PRISMS meta-review, representing data from 240 unique RCTs. The year of review publication ranged from 1995 to 2013, and included RCTs dated from 1979 to 2013. In addition we included 13 RCTs published since the last search dates of the included reviews (2010 for children, 2012 for adults and 2011 for ethnic groups; see Additional file 2 for details). (For clarity we refer to these as “update RCTs”.) A further two systematic reviews (which included a further four RCTs) and six RCTs were added after the pre-publication update. The RECURSIVE study included 24 RCTs with publication dates from 1993 to 2015.

25After excluding overlap, this represents 270 unique trials undertaken in at least 29 high- or middle-income countries: Argentina, Australia, Belgium, Brazil, Canada, Chile, Denmark, Finland, France, Germany, India, Israel, Italy, Jordan, Malaysia, Malta, Netherlands, New Zealand, Norway, Russia, Spain, Sweden, Switzerland, Taiwan, Trinidad, Turkey, UK, USA and Venezuela.

26In the 18 systematic reviews that reported the duration of follow-up in their included RCTs, the modal duration (in 10 of the reviews) was 12 months, with only 3% of reported RCTs falling outside the range of 3–24 months. The update RCTs had a similar profile, with 6 of 13 update RCTs having a duration of 12 months (range 3–30 months).

27Taking into consideration both study quality and total population size, 10 PRISMS reviews received an evidence weighting of three stars, 13 were weighted two star and two were weighted one star. Of the PRISMS update RCTs, four were judged to be at low risk of bias, five at high risk of bias and in four the risk of bias was unclear. Allocation concealment was judged as adequate in six of the 24 asthma studies included in the RECURSIVE review. Study quality is indicated in the first columns of Tables 3, 4 and 5, with details of the quality assessments in Additional file 4.

28Tables 3, 4, 5 and 6 provide summaries of the studies included in the PRISMS meta-review, update RCTs, the RECURSIVE review and pre-publication update with more detailed tables in Additional file 5.

29Figure 2 is a meta-Forest plot illustrating the meta-analyses (including three PRISMS 3* reviews and RECURSIVE) that report relative risks of admissions, A&E attendances and/or unscheduled consultations. Treatment event rates from the meta-analyses are in Table 7. These results suggest similar effects in adults, children and mixed populations.

30Hospitalisations were reported in 12 reviews. Six meta-analyses (four 3*, two 2*) showed that self-management support interventions led to fewer hospital admissions. Six narrative reviews of variable quality, reporting heterogeneous interventions, showed inconsistent effects on hospitalisations.

31Ten reviews reported A&E attendances. Four meta-analyses (three 3*, one 2*) reported a reduction in A&E attendances in the self-management intervention compared to control groups. Four narrative reviews (one 3*, three 2*) showed a reduction in A&E attendances in at least half of their included RCTs; one 3* review showed inconsistent results, and one 2* review showed no benefit on A&E attendances.

32Of the eight reviews that reported unscheduled care, three 3* meta-analyses reported fewer unscheduled consultations in participants who received a self-management intervention when compared to control. Furthermore, three 2* narrative reviews reported that self-management reduced unscheduled care in at least half their included trials. The remaining two small or poor quality reviews had inconsistent results.

33Of the 10 reviews that reported measures of control, three meta-analyses (two 3*, one 2*) and three narrative reviews reported a reduction in symptoms in participants who received self-management interventions compared to control groups. The other four narrative reviews (two 3*, two 2*) had inconsistent results or showed no benefit on symptom control. The broader concept of quality of life was reported as improved in some reviews, but not others.

34Six reviews reported a reduction in days missed from school or work. Two 3* meta-analyses, two small reviews each with only one RCT and five of the 13 RCTs in a 2* narrative synthesis of school-based interventions concluded that self-management interventions reduced absenteeism. A single RCT reported in a 3* narrative review in adults concluded that asthma education following A&E attendance had no effect on absenteeism.

35The systematic reviews encompassed a broad range of populations in diverse healthcare and demographic settings with consistently positive findings. For example, the reviews included all ages or only children or adults. Some focused on lower socioeconomic groups or ethnic minority communities. The reviews and RCTs identified in the PRISMS update typically built on this extensive generic evidence base and investigated interventions targeting specific groups such as urban, rural, deprived communities, cultural groups, adolescents or older adults. Table 8 summarises the key strategies used in trials to tailor interventions, or their mode of delivery, to different groups.

36Four reviews explored the impact of self-management in cultural groups. A 2* meta-analysis reported that culture-specific programmes reduced hospitalisations in children and improved quality of life in adults compared to generic interventions. A 3* narrative synthesis found only two RCTs testing culturally tailored interventions, one of which improved quality of life. The involvement of community health workers reduced use of healthcare resources in two thirds, and improved symptoms in all seven RCTs included in a 2* narrative review. An inpatient visit from a lay educator to Black or Latino children improved self-efficacy and action plan ownership 1 month post-discharge. In contrast, three generic interventions in US minority populations showed no improvement. Update RCTs, some underpowered, in indigenous populations had inconsistent outcomes.

37Two 3* meta-analyses demonstrated reduced use of healthcare resources (admissions, A&E attendances and unscheduled consultations) in adults recruited during A&E attendance (13 RCTs) and in children with a history of A&E attendance in the previous 12 months (38 RCTs). Neither review found improved markers of asthma control, though an update RCT in paediatric A&E attendees (low risk of bias) found that children discharged with an action plan had fewer symptoms at 28 days compared with usual care.

38School-based interventions, often using information technology-based programmes or delivered by peers, improved quality of life and, in some cases, reduced absenteeism. Generic parenting skills initiatives improved self-efficacy in families struggling to manage young children with asthma, with inconsistent effect on asthma outcomes.

39Two update RCTs reported interventions in older people that improved control and quality of life, and one reduced use of unscheduled care. A key feature of both complex interventions was a structured approach to tailoring in order to meet personal goals or address individual problems.

40A 3* meta-analysis (36 RCTs; 6090 participants of all ages recruited from primary and secondary care settings) defined optimal self-management as education including advice on self-monitoring and a written action plan that was supported by regular professional review. There is evidence that reducing the intensity of self-management education or level of clinical review may reduce its effectiveness.

41The components of an action plan were further defined in two 3* and three 2* reviews. In adults, self-monitoring based on peak flow or symptoms is equally effective. In a comparison in children, symptom-based plans were more effective at reducing unscheduled healthcare, and equally effective at improving most measures of asthma control; the exception was days with symptoms, which were reduced more by peak-flow-based than symptom-based plans. A 3* review concluded that action plans with between two and four action points, including recommendations on increasing inhaled corticosteroids and initiating oral corticosteroids, were consistently effective in reducing admissions and A&E attendances.

42One 3* meta-analysis demonstrated that self-management interventions that incorporated specific behaviour change techniques reduced unscheduled care and improved control. Meta-regression of the data from the 38 RCTs (7883 participants) concluded that active involvement of participants in the intervention was a key factor in reducing unscheduled healthcare. More specifically, identifying individual behavioural traits (e.g. rebelliousness, low perceived emotional support) in adolescents enabled targeted use of behavioural change techniques. A goal-setting approach proved challenging to implement in primary care settings.

43Two 1* narrative reviews investigated computer- or internet-based interactive self-management programmes. The effect on healthcare utilisation was inconsistent, confirmed by a recent review identified in the pre-publication update, though both showed improvement in symptoms and/or quality of life. Two update RCTs of web-based self-management programmes for adolescents also showed improved asthma control, and an extended follow-up of RCT participants concluded that these effects could be sustained 18 months after conclusion of the trial. Several school-based programmes used technology-based interventions to improve control and reduce absenteeism. Supported self-management using mobile phone technology currently has a limited and inconclusive evidence base, though a recent RCT in pregnancy demonstrated improved asthma control and quality of life.

44Resonating with the concept of ‘optimal’ self-management (education, an action plan and regular review), a 3* meta-analysis identified that omitting regular review (1 RCT) or reducing intensity of education (1 RCT) was associated with a smaller reduction in unscheduled consultations. A 2* meta-analysis analysed the findings of 18 RCTs (3006 participants) according to the components of the Chronic Care Model. Interventions that included all four components had a greater effect on adherence to inhaled corticosteroids compared to trials including self-management unsupported by the organisational components.

45A 3* narrative review of 14 RCTs (4588 participants) concluded that proactive organisational systems can increase action plan ownership by promoting uptake of asthma reviews and implementing (and monitoring) structured management systems for asthma care. A recent RCT of a structured approach to self-management education in both primary care and specialist units improved asthma control and reduced unscheduled care, and a large cluster RCT at low risk of bias showed an increased adherence to guidelines and reduced asthma symptoms by systematically providing individualised prompts to general practitioners and parents of children with asthma. Automatically linking an action plan to prescriptions given to patients being discharged from A&E improved clinician management and patient uptake of steroid courses.

46The RECURSIVE meta-analysis confirmed that self-management support interventions for people with asthma are associated with significant improvements in quality-of-life outcomes (SMD 0.26, 95% CI 0.12–0.39), significant small decreases in hospitalisation rates and costs (SMD −0.21, 95% CI −0.40 to −0.01), significant small decreases in A&E visits (SMD −0.25, 95% CI −0.49 to −0.01), and non-significant small increases in total healthcare costs (SMD 0.13, 95% CI −0.09 to 0.34). Figure 3 shows a Forest plot of the total costs.

47Figure 4 shows the overall permutation plot of the studies (n = 21) reporting data on both quality of life and healthcare utilisation. The majority of the studies on quality of life versus costs related to hospitalisations and A&E attendances were in the right-down quadrant, indicating cost-effectiveness (reduced healthcare utilisation and improved quality of life). However, in terms of total costs (n = 7), the picture was mixed with more studies around zero and the right-up quadrant, indicating that similar costs or small cost increases are necessary to achieve better quality of life.

48Four studies applied formal economic analyses; two showed that self-management support interventions were dominant (i.e. significantly better health outcomes with significantly lower costs), and two produced non-significant ratios between costs and benefits at levels likely to appeal to decision-makers (better outcomes with non-significant increases in costs) (see Additional file 5 for more details).

49Thus, the benefits derived by supported self-management interventions are associated with reductions in key areas of healthcare utilisation such as hospitalisations and A&E attendances and can be delivered at similar levels of total costs to usual care.

50Extensive evidence (n = 270 RCTs) derived from a broad range of demographic and healthcare settings reveals that supported self-management can reduce hospitalisations, A&E attendances and unscheduled consultations, and improve markers of control and quality of life for people with asthma. Core components of effective self-management are education, provision of an action plan and the support of regular professional review. Effectiveness has been demonstrated in diverse cultural, clinical and demographic groups, with evidence that tailored programmes have greater impact than generic interventions. A range of modes of delivery (including telehealthcare) may be employed to suit preferences and context. The cost of providing self-management support is offset by a reduction in hospitalisations and unscheduled healthcare.

51The literature on asthma self-management is particularly well developed and may thus be an exemplar for other LTCs. The 16 systematic reviews reporting effectiveness were typically large (five included data from >5000 participants) and had consistently positive results, suggesting a mature evidence base, unlikely to be influenced by further trials. Outcomes in subgroups were more often the subject of the update RCTs as the field moves on from demonstrating overall effectiveness to investigating the impact in specific target groups, demographic contexts, or mode of delivery.

52Self-management support for asthma is a complex intervention and successful interventions were multi-component, including education, trigger avoidance, teaching self-monitoring, optimal treatment strategies, promotion of adherence and behaviour change techniques, many of which are common to self-management in other LTCs. Appropriately in a variable condition, the hallmark of asthma self-management is the provision of an action plan with advice on recognising and responding to deterioration in control. People with asthma, however, have broader concerns as they accommodate the condition within their lives and the action plan needs to be embedded in support for ‘living with asthma’.

53Individuals with LTCs adjust medical regimes and self-management strategies to fit into their own lives and health beliefs. Meta-reviews, for example in type 2 diabetes, hypertension and asthma, have emphasised the importance of culturally tailored interventions. Self-management support can be provided by many different professionals, often specialist nurses or LTC educators, but in some contexts the key personnel were community health workers or peer counsellors. Traditionally education is delivered face-to-face, but increasingly technology-based interventions are being developed as alternatives.

54Self-management support interventions are an integral component of high-quality care for people with LTCs. Several of the systematic reviews demonstrated the synergy between self-management education and regular clinical review, and supported self-management is most effective when delivered within a proactive asthma management programme, or integrated within organisational routines. Only a minority of trials had follow-up periods over 12 months, and studies are needed to confirm long-term sustainability. Costs associated with self-management interventions are similar to usual care.

55Meta-reviews have some intrinsic strengths and limitations. The methodology enables the efficient review of a large body of evidence and thus provision of a comprehensive overview to inform policy and practice. However, it relies on the quality of the included systematic reviews (e.g. comprehensive search strategies, accurate data extraction and synthesis). We used the validated R-AMSTAR instrument to assess the quality of included systematic reviews. In contrast to GRADE (now recommended by the Cochrane Handbook), R-AMSTAR assesses the overall quality of the review, rather than assessing the quality of evidence individually for each outcome.

56Re-synthesising materials that have already been synthesised risks further loss of detail and has the potential for erroneous assumptions, especially if the primary focus of the review did not directly align with the questions of the meta-review. Overlap between the RCTs included in the systematic reviews may result in undue emphasis on commonly cited papers.

57Whilst some reviews and update RCTs directly compared interventions with or without specific components, or a specific mode of delivery, often the different interventions were compared to usual care, allowing only indirect comparison. A further limitation is that ‘usual care’ is rarely defined in RCTs, and the definition is even more unclear at meta-review level. Typically usual care is enhanced in the context of a trial, reducing the apparent impact of an intervention.

58Systematic reviews are only as current as their most-recent search, and meta-reviews add an additional time delay. In the PRISMS meta-review we therefore not only updated our search for systematic reviews, but also searched for RCTs published after the date of the last search used by the included systematic reviews. In addition, prior to publication we undertook forward citation on all the included systematic reviews, which identified two recent systematic reviews and six RCTs. None of these changed our conclusions, confirming the maturity of the evidence base.

59The two reviewers who undertook the screening and data extraction were not working independently; however, both projects ensured all the reviewers were fully trained and instituted random checks at every stage. Restricting inclusion to reviews with extractable RCT data maintained the quality of evidence, but may have resulted in some lower-grade but useful evidence being rejected.

60RECURSIVE was not restricted to formal cost-effectiveness studies – it had a broader focus and included studies reporting data on healthcare utilisation only, without a full effectiveness analysis including costs and quality of life. Some of the RCTs in the RECURSIVE meta-analysis used a more comprehensive definition of ‘total costs’ (e.g. based on societal perspective) compared to others; to account for this inconsistency, we also present the results on key sources of costs such as hospitalisation and A&E attendance rates.

61The PRISMS and RECURSIVE teams worked independently, but met regularly throughout the studies to optimise synergies. A further strength was the multidisciplinary team, including backgrounds in public health, general practice, epidemiology and health psychology, enabling a balanced interpretation.

62Supported self-management for asthma can reduce unscheduled care, improve asthma control and quality of life, and does not lead to significant increases in total healthcare costs. Effective self-management should be tailored to cultural, clinical and demographic characteristics and is most effective when delivered in the context of proactive LTC management. Healthcare organisations should prioritise and promote the provision of supported self-management for people with asthma.