Figures
- FIGURE 1
Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram.
- FIGURE 2
Star-shaped component network meta-analysis for adherence (continuous).
- FIGURE 3
Star-shaped component network meta-analysis for adherence (dichotomous).
- FIGURE 4
Star-shaped component network meta-analysis for health-related quality of life (as assessed by the St George's Respiratory Questionnaire).
- FIGURE 5
System-based logic model supplemented by the patient concept on the topic of therapy adherence. Red text represents areas of patient focus; purple text represents patient suggestions. QoL: quality of life.
- FIGURE 6
Process-oriented logic model supplemented by the patient concept on the topic of therapy adherence. Green squares represent areas of patient focus; purple text represents patient suggestions. QoL: quality of life.
Tables
- TABLE 1
Summary of findings: intervention components seeking to improve adherence (outcome adherence reported as continuous outcomes)
Components (versus standard care) SMD (95% CI) Participants (studies), n SUCRA (p-value) Certainty of the evidence (GRADE) Comments Education 1.26 (1.13–1.38) 859 (7 RCTs/1 observational) 0.9043 ⊕○○○
Very low¶,+Education, as a stand-alone component, may improve adherence compared to standard care but the evidence is very uncertain, based on the Cohen's d effect size# Education+motivation 0.83 (−1.06–2.72) 645 (7 RCTs/1 observational) 0.6720 ⊕○○○
Very low¶,+,§The association of education and motivation may improve adherence compared to standard care but the evidence is very uncertain, based on the Cohen's d effect size# Education+reminder+pulmonary rehabilitation 0.81 (−1.05–2.67) 492 (7 RCTs/1 observational) 0.6669 ⊕○○○
Very low¶,+,§The association of education, reminder and pulmonary rehabilitation may improve adherence compared to standard care but the evidence is very uncertain, based on the Cohen's d effect size# Education+motivation+telemedicine 0.54 (−0.09–1.17) 516 (7 RCTs/1 observational) 0.6171 ⊕○○○
Very low¶,+,§The association of education, motivation and telemedicine may improve adherence compared to standard care but the evidence is very uncertain, based on the Cohen's d effect size# Motivation 1.85 (1.19–2.50) 672 (7 RCTs/1 observational) ⊕○○○
Very low¶,+,ƒMotivation, as a stand-alone component, may improve adherence compared to standard care but the evidence is very uncertain, based on the Cohen's d effect size# Telemedicine 0.30 (−0.19–0.79) 620 (7 RCTs/1 observational) 0.5040 ⊕○○○
Very low¶,+,ƒTelemedicine, as a stand-alone component, may improve adherence compared to standard care but the evidence is very uncertain, based on the Cohen's d effect size# Standard care 467 (7 RCTs/1 observational) 0.3094 Education+psychosocial support −0.16 (−1.30–1.98) 560 (7 RCTs/1 observational) 0.2832 ⊕○○○
Very low¶,+,§The association of education and psychosocial support may not improve adherence compared to standard care but the evidence is very uncertain, based on the Cohen's d effect size# Education+motivation+pulmonary rehabilitation −0.70 (−0.97– −0.42) 583 (7 RCTs/1 observational) 0.0431 ⊕○○○
Very low¶,+,ƒThe association of education, motivation and pulmonary rehabilitation may not improve adherence compared to standard care, based on the Cohen's d effect size# Patient or population: COPD; settings: clinical, home and remote; intervention components: education, motivation, reminder, pulmonary rehabilitation, telemedicine, psychosocial support; comparison: standard care; follow-up: range 4–24 months. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group grades of evidence are as follows. High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: 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 certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect. SMD: standardised mean difference; SUCRA: surface under the cumulative ranking; RCT: randomised controlled trial. #: small effect 0.2, medium effect 0.5, large effect ≥0.8; ¶: downgraded by two levels for risk of bias because all the evidence is from studies at high risk of bias and some concern, and no study is at low risk of bias; +: downgraded by one level for inconsistency because of some variations in the direction of the effects; §: downgraded by two levels for imprecision because of the large confidence interval and the small sample size; ƒ: downgraded by one level for imprecision because of the small sample size.
- TABLE 2
Summary of findings for intervention components seeking to improve adherence (outcome adherence reported as dichotomous)
Components (versus standard care) Anticipated absolute effects (95% CI) Relative effect
(95% CI)Participants (studies), n SUCRA (p-value) Certainty of the evidence (GRADE) Comments Risk with standard
careRisk with components# Education 428 per 1000 781 per 1000
(628–884)OR 4.77
(2.25–10.14)528
(5 RCTs)0.9999 ⊕⊕○○
Low¶,+,§Education, as a stand-alone component, may result in a large increase in adherence compared to standard care, based on an MCID of 50 per 100 Education+motivation 428 per 1000 475 per 1000
(433–517)OR 1.21
(1.02–1.43)538
(5 RCTs)0.6339 ⊕○○○
Very low¶,+,ƒThe association of education and motivation may not improve adherence compared to standard care but the evidence is very uncertain, based on an MCID of 50 per 100 Telemedicine 428 per 1000 426 per 1000
(369–483)OR 0.99
(0.78–1.25)432 (5 RCTs) 0.1850 ⊕○○○
Very low¶,+Telemedicine, as a stand-alone component, may not improve adherence compared to standard care but the evidence is very uncertain, based on an MCID of 50 per 100 Standard care 383 (5 RCTs) 0.1812 Patient or population: COPD; settings: clinical (inpatient and outpatient) and community pharmacies; intervention components: education, motivation, telemedicine; comparison: standard care; follow-up: range 6–12 months. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group grades of evidence are as follows. High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: 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 certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect. SUCRA: surface under the cumulative ranking; OR: odds ratio; RCT: randomised controlled trial; MCID: minimal clinically important difference. #: the risk with components (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI), but it is based on the risk of the corresponding component; ¶: downgraded by two levels for risk of bias because all the evidence is from studies at high risk of bias and some concern, and no study is at low risk of bias; +: downgraded by one level for inconsistency because the CIs do not overlap, but the effect estimates are on the same side of the line of no effect; §: upgraded by one level because of the large OR; ƒ: downgraded by two levels for imprecision because the 95% CI crosses the threshold.
- TABLE 3
Summary of findings table for intervention components seeking to improve the HRQoL reported with the SGRQ (total score)
Components (versus standard care) MD (95% CI) Participants (studies), n SUCRA (p-value) Certainty of the evidence (GRADE) Comments Motivation −13.01 (−20.83– −5.18) 450 (6 RCTs) 0.9533 ⊕○○
Very low#,¶,+,§Motivation, as a stand-alone component, may improve the HRQoL measured with the SGRQ compared to standard care but the evidence is very uncertain, considering an MCID of −4 units Education −9.70 (−10.82– −8.57) 537 (6 RCTs) 0.8405 ⊕⊕○○
Low#,¶,+,ƒEducation, as a stand-alone component, may result in a large increase in the HRQoL measured with the SGRQ compared to standard care, considering an MCID of −4 units Education+motivation −4.12 (−7.72– −0.52) 551 (6 RCTs) 0.5752 ⊕○○○
Very low#,¶,##The association of education and motivation may improve the HRQoL measured with the SGRQ compared to standard care but the evidence is very uncertain, considering an MCID of −4 units Standard care 423 (6 RCTs) 0.2621 Telemedicine 0.90 (−3.70–5.50) 528 (6 RCTs) 0.1888 ⊕○○○
Very low#,¶,¶¶Telemedicine, as a stand-alone component, may not improve the HRQoL measured with the SGRQ compared to standard care but the evidence is very uncertain, considering an MCID of −4 units Education+psychosocial support 1.40 (−5.79–8.59) 521 (6 RCTs) 0.1801 ⊕○○○
Very low#,¶,++The association of education and psychosocial support may not improve the HRQoL measured with the SGRQ compared to standard care but the evidence is very uncertain, considering an MCID of −4 units Patient or population: COPD; settings: clinical (inpatient and outpatient) and home; intervention components: education, motivation, telemedicine, psychosocial support; comparison: standard care; follow-up: range 6–12 months. The GRADE Working Group grades of evidence are as follows. High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: 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 certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect. HRQoL: health-related quality of life; SGRQ: St George's Respiratory Questionnaire; MD: mean difference; SUCRA: surface under the cumulative ranking; RCT: randomised controlled trial; MCID: minimal clinically important difference. #: downgraded by two levels for risk of bias because all the evidence is from studies at high risk of bias and some concern, and no study is at low risk of bias; ¶: downgraded by one level for inconsistency because of some variations in the direction of the effects; +: upgraded by one level due to the large effect; §: downgraded by two levels for imprecision because the 95% CI crosses the thresholds of moderate and large effect (based on an MCID of −4 units); ƒ: downgraded by one level for imprecision because of the small sample size (<800 participants, rule of thumb based on the Cohen's small effect size); ##: downgraded by one level for imprecision because the 95% CI crosses the threshold of small effect (based on an MCID of −4 units); ¶¶: downgraded by one level for imprecision because the 95% CI crosses the threshold of small harm (based on an MCID of −4 units); ++: downgraded by two levels for imprecision because the 95% CI crosses the thresholds of small harm and benefit (based on an MCID of −4 units).
Supplementary Material
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Supplementary material ERR-0011-2024.SUPPLEMENT
