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Cochrane Database of Systematic Reviews

Toma de decisiones compartida para los pacientes con asma

Información

DOI:
https://doi.org/10.1002/14651858.CD012330.pub2Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 03 octubre 2017see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:

  1. Grupo Cochrane de Vías respiratorias

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Contraer

Autores

  • Kayleigh M Kew

    British Medical Journal Technology Assessment Group (BMJ‐TAG), BMJ Knowledge Centre, London, UK

  • Poonam Malik

    World Health Innovation Summit, Carlisle, UK

    STEM Labs, Research Office and Graduate School, University of Cumbria, Cumbria, UK

  • Krishnan Aniruddhan

    Victoria Hospital, Kirkcaldy, UK

  • Rebecca Normansell

    Correspondencia a: Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK

    [email protected]

Contributions of authors

KK wrote the Background and Methods sections of this review with support from PM.

For the full review, KK, PM, and RN screened search results and selected studies for inclusion. KK and RN finalised the included studies, extracted data, and assessed risk of bias in the included studies. KK conducted the analyses and wrote up the results, with input from RN. RN and KK assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RN, PM, and KA wrote the Discussion section, with input from KK. All review authors contributed to interpretation of findings and assisted in preparing the manuscript for submission.

Sources of support

Internal sources

  • Kayleigh M Kew, UK.

    Supported by St George's, University of London

External sources

  • National Institute for Health Research (NIHR), UK.

    Evidence to guide care in adults and children with asthma, 13/89/14

    This project was supported by the NIHR, via Cochrane Infrastructure, Cochrane Programme Grant, or Cochrane Incentive funding to the Cochrane Airways Group. The views and opinions expressed therein are those of the review authors and do not necessarily reflect those of the Systematic Reviews Programme, the NIHR, the NHS, or the Department of Health

Declarations of interest

KK is funded to prepare Cochrane reviews by a Programme Grant awarded by the NIHR to the Cochrane Airways Group.

PM has reported no conflicts.

KA is a consultant respiratory paediatrician with respiratory interest in the NHS. He has no alternative sources of funding.

RN is a qualified general practitioner and the deputy Co‐ordinating Editor of Cochrane Airways. She is funded by an NIHR grant to Cochrane Airways.

Acknowledgements

The Background and Methods sections of this review are based on a standard template used by Cochrane Airways. We are grateful for advice and editorial expertise provided by the Cochrane Airways staff.

Sally Spencer was the Editor for this review and commented critically on the review.

Version history

Published

Title

Stage

Authors

Version

2017 Oct 03

Shared decision‐making for people with asthma

Review

Kayleigh M Kew, Poonam Malik, Krishnan Aniruddhan, Rebecca Normansell

https://doi.org/10.1002/14651858.CD012330.pub2

2016 Aug 23

Shared decision‐making for people with asthma

Protocol

Kayleigh M Kew, Poonam Malik

https://doi.org/10.1002/14651858.CD012330

Differences between protocol and review

In the Dealing with missing data section, we changed the wording after "Where this was not possible, and we considered that the missing data may introduce serious bias" from "we explored the impact of including such studies in the overall assessment of results by a sensitivity analysis" to "we explored the impact in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) rating for that outcome."

Rebecca Normansell joined the review author team at the review stage. She extracted data and assessed studies for risk of bias, instead of PM, as had been planned. This was a more practical approach, as KK and RN are based in the same office.

We had planned to exclude cross‐over trials owing to the likelihood of carry‐over of effects, but for future updates, we will include the first phase of a cross‐over trial. We did not identify any relevant cross‐over trials during our searches.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Adult; Child; Humans;

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Study flow diagram.
Figuras y tablas -
Figure 1

Study flow diagram.

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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.

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

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

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

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

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

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

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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.

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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.

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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.

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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.

Figuras y tablas -
Summary of findings for the main comparison. Shared decision‐making compared with usual care for people with asthma
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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.
Figuras y tablas -
Table 1. Summary of study characteristics
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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.
Figuras y tablas -
Table 2. "Parents’ Views of Pediatricians’ Performance"; adapted from Clark 1998
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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]
Figuras y tablas -
Comparison 1. Shared decision‐making versus usual care
Ir a la tabla de la revisión