Alexander Hodkinson: Asthma can take over your life, but the right support makes it easier

Asthma is more than just struggling to breathe. It’s about having inflamed or sensitive airways that need to be monitored regularly and reviewed so they don’t react to triggers with symptoms like wheezing and a tight chest or coughing in the night. 

Supporting patients to self-manage their asthma has quickly become a more effective way to manage asthma exacerbations. This is supported with an evidence base from our earlier work: the “Practical Systematic Review of Self-Management Support (PRISMS) for long term conditions.” But as the models of self-management for asthma involve varied amounts of support from health professionals, which can lead to potential savings in terms of unscheduled care and financial costs, it was important that we try to determine which of the models are most effective.

We started by characterising the three broad models of self-management (i.e. minimally, regularly, and multidisciplinary supported self-management) and self-monitoring (involving delivery by telehealth and apps), considering for each the varied levels of support and review by professionals. This avoided the generalisability of categorising “supported self-management” into one individualised model for treating asthma. 

The most challenging aspect of this was ensuring that we had captured the appropriate levels of support and/or review with precision. Here, I had the unique opportunity to discuss the proposed models with patients who live with asthma across different spectrums of severity. This allowed us to get adequate scrutiny of our definitions and interpretations of the models, with direct input from patients who provided their own perspective on some of the day to day challenges they face living with asthma. 

Once a consensus was reached, we then needed to consider a novel and more robust approach to effectively evaluate the models in one single concise analysis. Here, I decided that the best approach was a network meta-analysis, which would allow us to compare and rank the different models for asthma self-management in a more precise way, utilising direct and indirect comparisons across trials. This is a unique methodological approach, and is the first time it’s been utilised in the field of self-management interventions. We are confident that it will provide a basis for such future analyses of complex self-management interventions of other long term diseases.    

Unsurprisingly, the findings from our review published in The BMJ confirm the clinical benefit of supported self-management for adults, adolescents, and children with asthma. But we have provided practical guidance for more specific models of service that are likely to be most effective and which can influence future policy investments. 

Specifically, we recommend the implementation of “regularly supported self-management” that offers professional review totalling at least two hours to establish self-management skills, while reserving multidisciplinary case management (i.e. action planning) for those with complex disease. 

Keeping people with asthma connected with their GPs and healthcare professionals (e.g. via tele/e-consultation) is the best way to improve their wellbeing and prevents avoidable visits to hospitals and emergency departments.

Alexander Hodkinson is a presidential fellow in evidence based medicine and medical statistics at the University of Manchester. Twitter: @drAlexHodkinson   

Competing interests: All authors declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.