Evidence
Alert

Supported self-management for people with asthma is the most effective model of care

Self-management of asthma means healthcare professionals educating, training and supporting people with asthma so they learn to manage their own condition. But there is little evidence to guide the level of support patients need from their healthcare team.

This study compared four self-management models for asthma by reviewing existing research papers.

The most effective model included more than two hours’ support from healthcare professionals. Typically, an initial discussion is followed up with regular reviews. This model improved quality of life for people whatever the severity of their asthma. It was much better at reducing unplanned or emergency healthcare use than so-called usual care, which relies upon patients using their inhaler, attending check-ups and receiving education in the form of brochures and SMS messages.

Intensive case management involving a range of professionals is only necessary for patients with severe asthma. Unsupported self-monitoring, or minimally supported self-management programmes were ineffective.

What’s the issue?

Six million people in the UK have asthma; and worldwide, it causes 250,000 deaths a year.

Self-management for people with asthma is recommended in UK by NICE and the British Thoracic Society/Scottish Intercollegiate Guideline Network, and internationally. It results in fewer hospital admissions and better quality of life. This approach develops the patients’ ability to manage their asthma. Education, training, and support improves patients’ knowledge, skills, and psychological resources.

There is a broad range of self-management models for asthma. They offer varying levels of review and support from healthcare professionals. But little is known about which model is most effective at reducing hospital admissions.

This study compares the effects of four different self-management models for asthma.

What’s new?

The research team categorised self-management approaches by the amount of support offered:

  • multidisciplinary supported self-management (a personalised action plan and face-to-face support from a team which could involve doctors, nurses, asthma educators, community workers)
  • regularly supported self-management (regular consultations with clinicians totalling more than two hours)
  • minimally supported self-management (limited consultations totalling less than two hours)
  • self-monitoring via apps, telehealth, or written diaries to measure symptoms or peak flow (a simple way of monitoring asthma by measuring how quickly you can blow air out of your lungs).

Researchers compared these models to education and usual care. They measured the effectiveness of each model by looking at unplanned healthcare use (hospital admissions and emergency visits) and patients’ quality of life.

The team compared and ranked the different self-management models using  evidence from 105 randomised controlled trials. Together, these trials included almost 28,000 adults and children (over the age of five) with asthma.

Self-management with regular, pre-planned support was more effective than all other models. It showed the greatest improvements in quality of life and the greatest reduction in healthcare use. This was particularly true in patients with mild to moderate symptoms of asthma.

Multidisciplinary case management interventions also showed a reduction in healthcare use compared with usual care, but only in patients with severe asthma. Unsupported, or minimally supported self-management programmes were ineffective.

Why is this important?

This study is the largest and most comprehensive meta-analysis on the effects of different levels of professional support in self-management of asthma. It suggests that an initial investment of time could be offset over the long term with less use of emergency care.

People with mild and moderate asthma need an initial self-management discussion, reinforced in regular reviews. At least two hours’ support was needed but it could come from any healthcare professional: doctor, nurse, educator, or community worker. This support helped patients establish self-management and improved their wellbeing. It also kept them connected to their GPs and healthcare team and prevented hospital visits.

The study found that case management involving an individualised written action plan for each patient is best suited to those with severe asthma.

The researchers suggest that remote consultation could prevent unnecessary hospital visits and protect patients during the COVID-19 outbreak.

What’s next?

These findings offer timely practical guidance for clinical practice. The researchers suggest that future policy should focus on implementing regularly supported self-management. Patients with severe asthma would need more support from multidisciplinary case management.

The trials included in this study did not explore long-term outcomes or patient experiences. So it remains unclear how long the initial, intensive phase of care – involving regular review and education – is needed. It may be that support from clinicians can become less intense once patients’ management of their condition is established.

The finding that self-monitoring was ineffective raises concerns. Smartphone apps allow people with asthma to log their symptoms. But they often do not offer advice on how patients should respond if their symptoms worsen. These apps should link self-monitoring to personalised actions recommended by the patient’s clinician.

The cost-effectiveness of the models of care would help with policy decision-making. The researchers stress that quality of life should not be neglected in policy decisions.

They want to further explore patient and lifestyle factors that may affect the effectiveness of self-management.

You may be interested to read

The full paper: Hodkinson A, and others. Self-management interventions to reduce healthcare use and improve quality of life among patients with asthma: systematic review and network meta-analysis. BMJ 2020;370:2521

My Lungs My Life website information for people living with asthma

NICE Guidance: Chronic asthma management [NG80], 2017

British Thoracic Society/Scottish Intercollegiate Guidelines Network: national Guideline on the management of asthma, 2019

Global Initiative for Asthma: Global Strategy for Asthma Management and Prevention, 2019

Clinical review paper on self-management: Pinnock H. Supported self-management for asthma. Breathe. 2015;11:98-109

Funding

This study is funded by the Evidence Synthesis Working Group, which is supported by the NIHR School for Primary Care Research. The study was supported by the NIHR Greater Manchester Patient Safety Translational Research Centre.

Commentaries

Study author

Current policy and guidelines recommend the use of written action plans to summarise discussions between patient and clinician. It is clear that these plans are often not regularly updated, perhaps because of organisational barriers or time constraints. Some patients therefore become disheartened and give up.

In this study, we recommend the use of regular supported self-management with a shift towards the use of specialised mobile apps or other internet tools, which could be designed to offer advice without the need for face-to-face medical support. Ensuring that people who suffer with asthma are properly connected with their GPs and healthcare professionals via online consultations, could go some way to help improve their self-management skills and well-being in the long-run.

The question is whether regularly supported self-management is less costly to the healthcare system. If so, we should consider this model of self-management more and invest in strategies to better streamline regular support and consultation.

Alexander Hodkinson, Presidential Fellow (Research), Centre for Primary Care and Health Services Research, University of Manchester

Specialist nurse

Guidelines promote self-management, but there is no clarity on the level of intervention required. A national standardised approach is needed, with health care professionals trained to this level.

Management plans need to be accepted and incorporated into everyday practice. We have some way to go. A review of our severe asthma service revealed that only 8.1% of those referred to us had an action plan.

Developing self-management skills enhances autonomy. Patients learn to recognise deterioration in their condition and put in place appropriate care strategies.

This could reduce the burden on the NHS and reduce healthcare expenditure. Better self-management could reduce side-effects from corticosteroids and unscheduled emergency care. It could lead to a better quality of life for asthma patients and reduce the number of unnecessary deaths.

Leanne Jo Holmes, Lead Clinical Nurse Specialist – Asthma and Severe Asthma, Manchester University NHS Foundation Trust

Conflicts of Interest

None declared.