Figures
- FIGURE 1
PRISMA flow diagram.
- FIGURE 2
Harvest plot summarising the findings of studies evaluating interventions to improve guidelines adherence for asthma assessment and maintenance management.
- FIGURE 3
Harvest plot summarising the findings of studies evaluating interventions to improve guidelines adherence for acute asthma attacks assessment and management.
- FIGURE 4
Harvest plot summarising the findings of studies evaluating differences in the adherence to asthma guidelines by specialists or generalists.
Tables
- TABLE 1
Systematic review (SR) questions
SR-1: Effectiveness of strategies aimed to improve adherence to guidelines on the diagnosis, assessment and long-term management of asthma Population Patients with a clinical diagnosis of asthma. Patients with a clinical suspicion of asthma, for studies evaluating asthma diagnosis. Intervention Interventions aimed to improve the adherence of clinicians to guidelines on the diagnosis, assessment and long-term management of asthma. Comparator Any other intervention aimed to improve the adherence of clinicians to guidelines on the diagnosis, assessment and long-term management of asthma, or no intervention. Outcomes Clinical outcomes such as frequency of acute attacks, episodes of hospitalisation, asthma symptoms, or quality of life. Process outcomes, such as adherence to specific guidelines components (e.g. prescription of inhaled corticosteroids for patients requiring maintenance treatment, or delivery of smoking cessation advice). Types of studies Interventional and observational comparative studies, including RCTs, cluster RCTs, comparative observational cohort studies or before-after studies. SR-2: Effectiveness of strategies aimed to improve adherence to guidelines on the diagnosis, assessment and management of acute attacks Population Patients with a clinical diagnosis of an acute asthma attack. Patients with a clinical suspicion of acute asthma attack, for studies evaluating asthma attack diagnosis. Intervention Interventions aimed to improve the adherence of clinicians to guidelines on the diagnosis, assessment and management of acute asthma. Comparator Any other intervention aimed to improve the adherence of clinicians to guidelines on the diagnosis, assessment and management of acute asthma, or no intervention. Outcomes Clinical outcomes such as need for hospital admission, duration of symptoms, treatment success or failure, need for intubation or mechanical ventilation. Process outcomes, such as adherence to specific guidelines components (e.g. prescription of oral corticosteroids for all patients with an acute attack leading to an emergency presentation or hospital admission). Types of studies Interventional and observational comparative studies, including RCTs, cluster RCTs, comparative observational cohort studies or before-after studies. SR-3: Process and clinical outcomes in patients managed by specialists or generalists Population Patients with a clinical diagnosis of asthma or acute asthma attack. Patients with a clinical suspicion of asthma or acute asthma attack, for studies evaluating asthma or acute asthma attack diagnosis, respectively. Exposure A Management by an asthma specialist (respiratory physician or allergist). Exposure B Management by a generalist (general practitioner or internist, not specialised in asthma). Outcomes For studies evaluating the diagnosis, assessment or long-term management of asthma: clinical outcomes such as frequency of acute attacks, episodes of hospitalisation, asthma symptoms, or quality of life. Process outcomes, such as adherence to specific guidelines components (e.g. prescription of inhaled corticosteroids for patients requiring maintenance treatment, or delivery of smoking cessation advice).
For studies evaluating the diagnosis, assessment or management of acute asthma attacks: clinical outcomes such as need for hospital admission, duration of symptoms, treatment success or failure, need for intubation or mechanical ventilation. Process outcomes, such as adherence to specific guidelines components (e.g. prescription of oral corticosteroids for all patients with an acute attack leading to an emergency presentation or hospital admission).Types of studies Interventional and observational comparative studies, including RCTs, cluster RCTs, comparative observational cohort studies or before-after studies. RCT: randomised controlled trial.
- TABLE 2
Healthcare profession/level of training and subsequent categorisation in the analyses of the survey
Category n (%) Categories in the analyses 1st survey: mild type 2 and severe type 2 asthma Allergy–asthma specialist 22 (2.5) Allergy doctor Allergy specialist 133 (15.2) Allergy doctor Trainee in allergy 9 (1.0) Allergy doctor Respiratory–asthma specialist 123 (14.1) Respiratory doctor Respiratory doctors 456 (52.1) Respiratory doctor Trainee in respiratory medicine 34 (3.9) Respiratory doctor General practitioner 48 (5.5) Generalist Internist 28 (3.2) Generalist Specialist nurse 13 (1.5) Generalist Trainee general practitioner 4 (0.5) Generalist Trainee in internal medicine 4 (0.5) Generalist Nurse trainee 1 (0.1) Generalist 2nd survey: non-type 2 asthma Allergy–asthma specialist 30 (4.4) Allergy doctor Allergy specialist 163 (24.0) Allergy doctor Trainee in allergy 12 (1.8) Allergy doctor Respiratory–asthma specialist 80 (11.8) Respiratory doctor Respiratory doctors 245 (36.1) Respiratory doctor Trainee in respiratory medicine 13 (1.9) Respiratory doctor General practitioner 99 (14.6) Generalist Internist 16 (2.4) Generalist Specialist nurse 14 (2.1) Generalist Trainee general practitioner 4 (0.6) Generalist Trainee in internal medicine 2 (0.3) Generalist Nurse trainee 1 (0.2) Generalist - TABLE 3
Preferred diagnostic procedure in different subtypes of asthma as reported in the online survey
Allergy doctors (%) Respiratory doctors (%) Generalists (%) p-value# Mild type 2 asthma Spirometry with reversibility test 95.0 96.4 86.9 0.001 Peak flow 24.1 27.8 39.3 0.04 FeNO 49.0 58.7 41.7 <0.0001 Blood eosinophils 57.2 73.7 63.1 <0.0001 Total IgE 49.7 63.6 41.7 0.006 Skin prick test 93.1 65.4 50.0 <0.0001 Specific IgE 53.1 38.0 32.1 0.001 Chest radiograph 36.6 55.7 23.8 <0.0001 ENT examination 31.7 31.4 29.8 0.95 Bronchoscopy 0 2.5 1.2 0.12 Bronchial provocation 19.3 31.9 20.2 0.002 Bacterial culture 4.1 7.4 7.1 0.38 Detailed history 70.3 68.1 66.7 0.82 Chest auscultation 55.9 48.3 41.7 0.10 Serial peak flow 53.1 62.9 75.0 0.004 Severe type 2 asthma Spirometry with reversibility test 98.0 96.4 85.1 0.001 Peak flow 19.2 24.1 25.5 0.55 FeNO 74.8 79.9 48.9 0.004 Blood eosinophils 79.8 85.9 68.1 0.006 Total IgE 60.6 77.6 36.2 <0.0001 Skin prick test 99.0 78.4 57.4 <0.0001 Specific IgE 55.6 41.0 34.0 0.01 Chest radiograph 39.4 59.8 27.7 <0.0001 ENT examination 40.4 34.6 27.7 0.30 Bronchoscopy 1.0 1.7 2.1 0.86 Bronchial provocation 8.0 10.8 4.3 0.30 Bacterial culture 9.1 8.6 8.5 0.99 Detailed history 78.8 79.5 80.8 0.96 Chest auscultation 83.8 81.7 76.6 0.57 Serial peak flow 37.4 41.3 48.9 0.42 Check prescriptions 76.8 85.3 83.0 0.13 Assess inhalation technique 92.9 91.7 85.1 0.26 Non-type 2 asthma Spirometry with reversibility test 65.4 69.5 49.2 <0.0001 Peak flow 14.6 21.0 28.4 0.009 FeNO 50.2 49.7 26.9 <0.0001 Blood eosinophils 53.2 61.2 38.1 <0.0001 Total IgE 44.9 479 19.4 <0.0001 Skin prick test 26.3 14.2 9.0 <0.0001 Specific IgE 22.4 25.2 11.9 0.007 Chest radiograph 49.30 55.9 30.6 <0.0001 ENT examination 30.2 23.1 11.2 <0.0001 Bronchoscopy 1.5 3.2 2.2 0.42 Bronchial provocation 1.5 4.1 2.2 0.17 Bacterial culture 17..1 17.8 4.5 0.001 Detailed history 65.8 67.8 53.7 0.01 Chest auscultation 68.8 71.2 61.2 0.12 Occupational evaluation 55.1 66.3 56.0 0.02 Check adherence 66.3 71.0 59.7 0.06 Assess inhaler technique 72.2 79.9 64.9 0.002 FeNO: exhaled nitric oxide fraction; Ig: immunoglobulin; ENT: ear, nose and throat. #: refers to comparisons among the three groups, using the Chi-squared test.
- TABLE 4
Types of studies evaluating the adherence to asthma guidelines and the proportion of studies demonstrating beneficial clinical and adherence outcomes among the studies evaluating such outcomes
Total N RCTs n Before-after n Comparative observational study n Beneficial clinical outcomes Beneficial process outcomes Assessment and management of asthma during stable disease state Additional patient specific input by a specialised health professional 13 8 2 3 8/12 (66.7) 10/11 (90.9) Asthma care pathway 4 1 3 2/2 (100) 3/3 (100) Computer decision-support systems 7 6 1 3/5 (60) 4/7 (57.1) Introduction of a local or national guideline 4 2 1 1 0/1 (0) 2/4 (50) Medical education 12 7 5 1/4 (25) 5/10 (50) Quality improvement process 11 3 7 1 4/6 (66.7) 8/10 (80) Participation in a clinical trial 1 1 0/1 (0) 0/1 (0) Assessment and management of acute asthma attacks Acute asthma care pathway 12 11 1 1/8 (12.5) 10/12 (83.3) Additional patient specific input by a specialised health professional 1 1 0/0 (N/A) 1/1 (100) Computer decision-support systems 1 1 0/0 (N/A) 1/1 (100) Introduction of a local or national guideline 1 1 0/0 (N/A) 0/1 (0) Medical education 1 1 0/0 (N/A) 0/1 (0) Quality improvement process 9 2 5 2 2/3 (66.7) 6/7 (85.7) Data are presented as n/N (%), unless otherwise stated. RCT: randomised controlled trial; N/A: not available.
Vol 30 Issue 161
Table of Contents
ERS/EAACI statement on adherence to international adult asthma guidelines
