Systematic meta-review of supported self-management for asthma: a healthcare perspective

BACKGROUND: Supported self-management has been recommended by asthma guidelines for three decades; improving current suboptimal implementation will require commitment from professionals, patients and healthcare organisations. The Practical Systematic Review of Self-Management Support (PRISMS) meta-review and Reducing Care Utilisation through Self-management Interventions (RECURSIVE) health economic review were commissioned to provide a systematic overview of supported self-management to inform implementation. We sought to investigate if supported asthma self-management reduces use of healthcare resources and improves asthma control; for which target groups it works; and which components and contextual factors contribute to effectiveness. Finally, we investigated the costs to healthcare services of providing supported self-management. METHODS: We undertook a meta-review (systematic overview) of systematic reviews updated with randomised controlled trials (RCTs) published since the review search dates, and health economic meta-analysis of RCTs. Twelve electronic databases were searched in 2012 (updated in 2015; pre-publication update January 2017) for systematic reviews reporting RCTs (and update RCTs) evaluating supported asthma self-management. We assessed the quality of included studies and undertook a meta-analysis and narrative synthesis. RESULTS: A total of 27 systematic reviews (n = 244 RCTs) and 13 update RCTs revealed that supported self-management can reduce hospitalisations, accident and emergency attendances and unscheduled consultations, and improve markers of control and quality of life for people with asthma across a range of cultural, demographic and healthcare settings. Core components are patient education, provision of an action plan and regular professional review. Self-management is most effective when delivered in the context of proactive long-term condition management. The total cost (n = 24 RCTs) of providing self-management support is offset by a reduction in hospitalisations and accident and emergency visits (standard mean difference 0.13, 95% confidence interval -0.09 to 0.34). CONCLUSIONS: Evidence from a total of 270 RCTs confirms that supported self-management for asthma can reduce unscheduled care and improve asthma control, can be delivered effectively for diverse demographic and cultural groups, is applicable in a broad range of clinical settings, and does not significantly increase total healthcare costs. Informed by this comprehensive synthesis of the literature, clinicians, patient-interest groups, policy-makers and providers of healthcare services should prioritise provision of supported self-management for people with asthma as a core component of routine care. SYSTEMATIC REVIEW REGISTRATION: RECURSIVE: PROSPERO CRD42012002694 ; PRISMS: PROSPERO does not register meta-reviews

Errorless Compliance to Parental Requests III: Group Parent Training With Parent Observational Data and Long-Term Follow-Up

Errorless compliance training has recently been developed as a nonintrusive approach to improving generalized child cooperation (Ducharme & Popynick, 1993; Ducharme et al., 1994). In the present study, we investigated issues of efficiency, durability, and generality of treatment effects to ensure optimal treatment utility. Parents of five children with developmental disabilities and severe oppositional behavior were trained in a group format to conduct errorless compliance assessment and treatment procedures. Parent-collected data and research assistant-collected videotape data were used to determine generality of effects. We examined long-term maintenance by conducting intensive follow-up assessment up to 15 months after treatment completion. Both parent and research assistant-collected data suggested that the group format for errorless compliance training was effective in enhancing treatment and generalization effects. The effects were also durable, with all children demonstrating high levels of compliance during long-term follow-up assessment

Proximal and distal effects of play on child compliance with a brain-injured parent.

Individuals with brain injury may experience severe cognitive and other impairments. For brain-injured parents, such deficits may be associated with child behavior problems, including noncompliance. We assessed the effects of a play period conducted by a brain-injured father on the compliance of his son, who had become uncooperative with his father after the injury. The child consistently demonstrated improved compliance during proximal and distal compliance sessions that followed father-son play periods

Behavioral momentum and stimulus fading in the acquisition and maintenance of child compliance in the home

The provision of a series of requests to which compliance is highly likely (high-probability requests) immediately antecedent to low-probability requests has been used to establish behavioral momentum of compliance. We evaluated a fading procedure for maintaining high levels of compliance obtained with high-probability requests. Fading involved a systematic reduction in the number of high-probability requests and an increase in the latency between the high- and low-probability requests. High levels of compliance for both “do” and “don't” requests were maintained for 16 weeks in a 5-year-old boy with developmental disabilities after the high-probability request sequence was faded. Similar maintenance was obtained for “do” requests in a 15-year-old girl with developmental disabilities. For this subject, however, the high-probability request sequence was ineffective with “don't” requests. When “don't” requests were phrased as “do” requests, the high-probability request sequence produced high levels of compliance to the low-probability request. High levels of compliance to these “do” requests were maintained for 16 weeks after the high-probability request sequence was faded