title: Implementing supported self-management for asthma: a systematic review and suggested hierarchy of evidence of implementation studies.
abstract: BACKGROUND
  Asthma 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.
  
  
  METHODS
  We 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).
  
  
  RESULTS
  We 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.
  
  
  CONCLUSIONS
  Our 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.
  
  
  BACKGROUND
  PROSPERO (registration number: CRD42012002898 ) Accessed 24 May 2015.
authors.affiliation: Asthma UK Centre for Applied Research, Allergy and Respiratory Research Group, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK. hilary.pinnock@ed.ac.uk.
authors.forename: Hilary
authors.initials: H
authors.lastname: Pinnock
authors.affiliation: Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, E1 2AB, UK. eleniepi82@gmail.com.
authors.forename: Eleni
authors.initials: E
authors.lastname: Epiphaniou
authors.affiliation: Centre for Technology Enabled Health, Coventry University, Coventry, CV1 5FB, UK. gemma.pearce@coventry.ac.uk.
authors.forename: Gemma
authors.initials: G
authors.lastname: Pearce
authors.affiliation: Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, E1 2AB, UK. hannahlparke@gmail.com.
authors.forename: Hannah
authors.initials: H
authors.lastname: Parke
authors.affiliation: Department of Primary Care Health Sciences, New Radcliffe House, 2nd floor, Walton Street, Oxford, OX2 6GG, UK. trish.greenhalgh@phc.ox.ac.uk.
authors.forename: Trish
authors.initials: T
authors.lastname: Greenhalgh
authors.affiliation: Asthma UK Centre for Applied Research, Allergy and Respiratory Research Group, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK. aziz.sheikh@ed.ac.uk.
authors.forename: Aziz
authors.initials: A
authors.lastname: Sheikh
authors.affiliation: Asthma UK Centre for Applied Research, Allergy and Respiratory Research Group, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK. c.j.griffiths@qmul.ac.uk.
authors.forename: Chris J
authors.initials: CJ
authors.lastname: Griffiths
authors.affiliation: Public Health and Primary Care, Multidisciplinary Evidence Synthesis Hub (mEsh), Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, E1 2AB, UK. s.j.c.taylor@qmul.ac.uk.
authors.forename: Stephanie J C
authors.initials: SJ
authors.lastname: Taylor
mesh_terms: D001249:Asthma / Q000628:therapy*; D005260:Female; D006801:Humans; D012189:Retrospective Studies; D012648:Self Care / Q000379:methods*; D011795:Surveys and Questionnaires