Shared decision‐making for people with asthma

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

doi:10.1002/14651858.CD012330.pub2

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Figure 1

Study flow diagram.

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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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Analysis 1.1

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

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Analysis 1.2

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

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Analysis 1.3

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

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Analysis 1.4

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

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Analysis 1.5

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

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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
Outcomes		Risk with usual care	Risk with shared decision‐making	Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
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)	⊕⊕⊕⊝ MODERATE^a	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 LOW^a,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)	⊕⊕⊝⊝ LOW^a,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)	⊕⊕⊕⊝ MODERATE^e	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)	⊕⊕⊝⊝ LOW^f	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)	⊕⊕⊕⊝ MODERATE^a	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.

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.

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 (GEE^a)
Reassuring and encouraging^b	4.63	4.42	0.006
Look into how family managed day to day^b	3.98	3.69	0.02
Describe how child should be fully active^c	71.%	59%	0.007
Describe at least 1 of 3 goals: child should sleep through the night; have no symptoms when active; be fully active^c	75%	64%	0.07
Give information to relieve specific worries^b	4.1	3.9	0.007
Enable family to know how to make asthma management decisions^b	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.

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]

Comparison 1. Shared decision‐making versus usual care

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