Abstract
BackgroundAsthma self-management remains poorly implemented in clinical practice despite overwhelming evidence of improved healthcare outcomes, reflected in guideline recommendations over three decades. To inform delivery in routine care, we synthesised evidence from implementation studies of self-management support interventions.MethodsWe systematically searched eight electronic databases (1980 to 2012) and research registers, and performed snowball and manual searches for studies evaluating implementation of asthma self-management in routine practice. We included, and adapted systematic review methodology to reflect, a broad range of implementation study designs. We extracted data on study characteristics, process measures (for example, action plan ownership), asthma control (for example, patient reported control questionnaires, days off school/work, symptom-free days) and use of health services (for example, admissions, emergency department attendances, unscheduled consultations). We assessed quality using the validated Downs and Black checklist, and conducted a narrative synthesis informed by Kennedy’s whole systems theoretical approach (considering patient, practitioner and organisational components and the interaction between these).ResultsWe included 18 studies (6 randomised trials, 2 quasi-experimental studies, 8 with historical controls and 3 with retrospective comparators) from primary, secondary, community and managed care settings serving a total estimated asthma population of 800,000 people in six countries. In these studies, targeting professionals (n = 2) improved process, but had no clinically significant effect on clinical outcomes. Targeting patients (n = 6) improved some process measures, but had an inconsistent impact on clinical outcomes. Targeting the organisation (n = 3) improved process measures, but had little/no effect on clinical outcomes. Interventions that explicitly addressed patient, professional and organisational factors (n = 7) showed the most consistent improvement in both process and clinical outcomes. Authors highlighted the importance of health system commitment, skills training for professionals, patient education programmes supported by regular reviews, and on-going evaluation of implementation effectiveness.ConclusionsOur methodology offers an exemplar of reviews synthesising the heterogeneous implementation literature. Effective interventions combined active engagement of patients, with training and motivation of professionals embedded within an organisation in which self-management is valued. Healthcare managers should consider how they can promote a culture of actively supporting self-management as a normal, expected, monitored and remunerated aspect of the provision of care.Systematic review registrationPROSPERO (registration number: CRD42012002898) Accessed 24 May 2015Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-015-0361-0) contains supplementary material, which is available to authorized users.
Highlights
Asthma self-management remains poorly implemented in clinical practice despite overwhelming evidence of improved healthcare outcomes, reflected in guideline recommendations over three decades
We presented our preliminary findings and draft conclusions at a multidisciplinary end-of-project workshop attended by 32 policymakers, commissioners, health service managers, healthcare professionals, academics, and patient representatives
Statement of principal findings This review has shown that complex whole systems interventions that explicitly address patient education, professional training and organisational commitment are associated with improvement in process measures [36,37,38, 42,43,44,45,46,47], markers of asthma control [37, 38, 42, 44, 45], and reduced use of unscheduled healthcare [37, 38, 42,43,44,45,46]
Summary
Asthma self-management remains poorly implemented in clinical practice despite overwhelming evidence of improved healthcare outcomes, reflected in guideline recommendations over three decades. The policy focus has shifted to the translational gap between research and practice [16], echoed by the development of a Dissemination and Implementation (D and I) research paradigm [17, 18], and a growing emphasis on ‘research impact’ [19]. These initiatives may provide the impetus required to move health service research from (often ineffective) dissemination to active translation of efficacious interventions into practical approaches for effective implementation within diverse healthcare systems [15, 20]
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