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Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 Shared decision‐making versus usual care, Outcome 1 Quality of life improvement (AQLQ responders).
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Analysis 1.1

Comparison 1 Shared decision‐making versus usual care, Outcome 1 Quality of life improvement (AQLQ responders).

Comparison 1 Shared decision‐making versus usual care, Outcome 2 Quality of life scores (ITG‐ASF).
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Analysis 1.2

Comparison 1 Shared decision‐making versus usual care, Outcome 2 Quality of life scores (ITG‐ASF).

Comparison 1 Shared decision‐making versus usual care, Outcome 3 Quality of life scores (mini‐AQLQ).
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Analysis 1.3

Comparison 1 Shared decision‐making versus usual care, Outcome 3 Quality of life scores (mini‐AQLQ).

Comparison 1 Shared decision‐making versus usual care, Outcome 4 Medication adherence.
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Analysis 1.4

Comparison 1 Shared decision‐making versus usual care, Outcome 4 Medication adherence.

Comparison 1 Shared decision‐making versus usual care, Outcome 5 Exacerbations of asthma.
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Analysis 1.5

Comparison 1 Shared decision‐making versus usual care, Outcome 5 Exacerbations of asthma.

Comparison 1 Shared decision‐making versus usual care, Outcome 6 Asthma well controlled.
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Analysis 1.6

Comparison 1 Shared decision‐making versus usual care, Outcome 6 Asthma well controlled.

Summary of findings for the main comparison. Shared decision‐making compared with usual care for people with asthma

Shared decision‐making compared with usual care for people with asthma

Patient or population: adults and children with asthma
Setting: primary care/outpatient clinics
Intervention: shared decision‐making
Comparison: usual care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with usual care

Risk with shared decision‐making

Asthma‐related quality of life

(follow‐up: 6 to 24 months)

AQLQ responders

556 per 1000

704 per 1000
(608 to 784)

OR 1.90
(1.24 to 2.91)

371
(1 RCT)

⊕⊕⊕⊝
MODERATEa

Participants achieving > 0.5‐point improvement (MCID for this scale)

ITG‐ASF daytime symptom scale

Mean ITG‐ASF daytime symptom score was 12

MD 4 higher
(3.54 lower to 11.54 higher)

53
(1 RCT)

⊕⊝⊝⊝
VERY LOWa,b,c

Higher score = Better quality of life

The same study also reported mean night‐time symptom scale and functional limitation scale (see Analysis 1.2).

Mini‐AQLQ

Mini‐AQLQ score was 5.5

MD 0.4 higher
(0.18 higher to 0.62 higher)

371
(1 RCT)

⊕⊕⊝⊝
LOWa,c,d

Higher score = Better quality of life. MCID 0.5

Parent/patient satisfaction

Presentation on forest plot not possible; summarised narratively in text and Table 2

Medication adherence

(follow‐up: 12 to 24 months)

ICS only

The ICS adherence was 0.59

MD 0.22 higher
(0.11 higher to 0.33 higher)

371
(1 RCT)

⊕⊕⊕⊝
MODERATEe

Adherence calculated using continuous medication acquisition (CMA) from pharmacy data. Maximum score 1.

The same study reported all‐medication adherence (see Analysis 1.4).

Exacerbations of asthma

(follow‐up: 6 months)

Requiring ED visit

222 per 1,000

77 per 1,000
(14 to 314)

OR 0.29
(0.05 to 1.60)

53
(1 RCT)

⊕⊕⊝⊝
LOWf

The same study reported exacerbations requiring hospital admission, "specialist visits", and GP visits (see Analysis 1.5).

Asthma control

(follow‐up: 12 to 24 months)

Asthma well controlled; ATAQ = 0

No control group risk presented

Not estimable

OR 1.90
(1.26 to 2.87)

371

(1 RCT)

⊕⊕⊕⊝
MODERATEa

Lower score = Better asthma control

A different small study reported asthma control on ACT and ACQ (see Analysis 1.6).

Adverse events (all)

Included trials did not measure or report any adverse events.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

ACQ: Asthma Control Questionnaire; ACT: Asthma Control Test; AQLQ: asthma quality of life questionnaire; ATAQ: Asthma Therapy Assessment Questionnaire CI: confidence interval; ED: emergency department; GP: general practitioner; ICS: inhaled corticosteroid; ITG‐ASF: Integrated Therapeutics Group ‐ Child Asthma Short Form; MCID: mean clinically important difference; MD: mean difference; OR: odds ratio; RCT: randomised controlled trial; RR: risk ratio.

GRADE Working Group grades of evidence.
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

aRisk of performance and detected bias. Downgraded once.

bOne study. Confidence intervals include possible harm and benefit of intervention. Downgraded once.

cOnly quality of life subscales reported. Downgraded once for indirectness.

dAlthough the mean difference for this scale lies below the MCID, the responder analysis suggests that significantly more people achieved the MCID change with the intervention. No downgrade.

eAdherence calculated using continuous medication acquisition from pharmacy data. This is a proxy measure and may overestimate true adherence. Downgraded once.

fOne study. Confidence intervals very wide and include possible harm and benefit of intervention. Downgraded twice.

Figures and Tables -
Summary of findings for the main comparison. Shared decision‐making compared with usual care for people with asthma
Table 1. Summary of study characteristics

Study ID

Country

Population

Age (years)

Design

Intervention

Aimed at

Control

Clark 1998

USA

74 physicians; 637 children

1 to 12

Cluster RCT

SDM seminars

HCPs

Usual care

Fiks 2015

USA

60 families

6 to 12

Individual RCT

SDM portal

HCPs and patients/parents

Usual care + decision support

van Bragt 2015

Holland

33 children

6 to 12

Cluster RCT

SDM online tool

HCPs and patients/parents

Enhanced usual care

Wilson 2010

USA

612 adults

18 to 65

Individual RCT

SDM structured sessions

HCPs

1. Guideline‐led decision‐making

2. Usual care

HCP: healthcare provider; RCT: randomised controlled trial; SDM: shared decision‐making.

Figures and Tables -
Table 1. Summary of study characteristics
Table 2. "Parents’ Views of Pediatricians’ Performance"; adapted from Clark 1998

Was/did the clinician:

SDM

Control

P value

(GEEa)

Reassuring and encouragingb

4.63

4.42

0.006

Look into how family managed
day to dayb

3.98

3.69

0.02

Describe how child should be fully
activec

71.%

59%

0.007

Describe at least 1 of 3 goals:
child should sleep through the
night; have no symptoms when
active; be fully activec

75%

64%

0.07

Give information to relieve specific
worriesb

4.1

3.9

0.007

Enable family to know how to make
asthma management decisionsb

4.3

4.2

0.07

aGEE method to assess "Time2" (follow‐up) scores with baseline scores and group assignment as covariates in regression models.
bA Likert‐type response scale was used, where 1 = strongly disagree and 6 = strongly agree.
cQuestion asked at "Time2" (follow‐up) only.

NB: A total of 472 parents were followed up; numbers in each group are not given.

Figures and Tables -
Table 2. "Parents’ Views of Pediatricians’ Performance"; adapted from Clark 1998
Comparison 1. Shared decision‐making versus usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Quality of life improvement (AQLQ responders) Show forest plot

1

Odds Ratio (M‐H, Random, 95% CI)

Totals not selected

2 Quality of life scores (ITG‐ASF) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 ITG‐ASF night‐time symptom scale

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2.2 ITG‐ASF daytime symptom scale

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2.3 ITG‐ASF functional limitation scale

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 Quality of life scores (mini‐AQLQ) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

4 Medication adherence Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

4.1 All medications

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4.2 ICS only

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

5 Exacerbations of asthma Show forest plot

1

Odds Ratio (M‐H, Random, 95% CI)

Totals not selected

5.1 Requiring hospital admission

1

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

5.2 Requiring ED visit

1

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

5.3 Requiring specialist visit

1

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

5.4 Requiring GP visit

1

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

6 Asthma well controlled Show forest plot

2

Odds Ratio (Fixed, 95% CI)

Totals not selected

6.1 ACQ < 1

1

Odds Ratio (Fixed, 95% CI)

0.0 [0.0, 0.0]

6.2 ACT > 22

1

Odds Ratio (Fixed, 95% CI)

0.0 [0.0, 0.0]

6.3 ATAQ = 0

1

Odds Ratio (Fixed, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 1. Shared decision‐making versus usual care