Rukhsana Ayub, Naveed Yousuf, Nadia Shabnam, Muhammad Azeem Ashraf, Azam S Afzal, Ayesha Rauf, Danish Hassan Khan, Faiza Kiran
Investigating the internal structure of multiple mini interviews-A perspective from Pakistan
PloS one
despite proven efficacy improving symptoms reducing exacerbations many patients asthma fully adherent steroid inhaler suboptimal adherence leads poorer clinical outcomes increased health service utilisation identified contributing factor third asthma deaths uk reasons nonadherence vary variety interventions proposed help people improve treatment adherenceto assess efficacy safety interventions intended improve adherence inhaled corticosteroids among people asthmawe identified trials cochrane airways trials register contains studies identified multiple electronic searches handsearches sources also searched trial registries reference lists primary studies conducted recent searches 18 november 2016we included parallel cluster randomised controlled trials duration conducted setting included studies reported fulltext articles published abstracts unpublished data included trials adults children asthma current prescription inhaled corticosteroid ics monotherapy combination longacting beta2agonist laba eligible trials compared intervention primarily aimed improving adherence ics versus usual care alternative interventiontwo review authors screened searches extracted study characteristics outcome data included studies assessed risk bias primary outcomes adherence ics exacerbations requiring least oral corticosteroids asthma control graded results presented evidence summary findings tables comparisonwe analysed dichotomous data odds ratios continuous data mean differences standardised mean differences using randomeffects model described skewed data narratively made priori assumptions trials would categorised conducted metaanalyses treatments participants underlying clinical question similar enough pooling make sensewe included 39 parallel randomised controlled trials rcts involving adults children asthma 28 n 16303 contributed data least one metaanalysis followup ranged two months two years median six months trials conducted mainly highincome countries studies reported measure adherence ics variety outcomes quality life asthma control studies generally low unclear risk selection bias high risk biases associated blinding considered around half studies high risk attrition bias selective outcome reportingwe classified studies four comparisons adherence education versus control 20 studies electronic trackers reminders versus control 11 studies simplified drug regimens versus usual drug regimens four studies schoolbased directly observed therapy three studies two studies described separatelyall pooled results adherence education electronic trackers reminders simplified regimens showed better adherence controls analyses limited studies using objective measures revealed adherence education showed benefit 20 percentage points control 95 confidence interval ci 752 3274 five studies lowquality evidence electronic trackers reminders led better adherence 19 percentage points 95 ci 1447 2526 six studies moderatequality evidence simplified regimens led better adherence 4 percentage points 95 ci 188 616 three studies moderatequality evidence confidence evidence reduced risk bias inconsistencyimprovements adherence consistently translated observable benefit clinical outcomes pooled analyses none intervention types showed clear benefit primary clinical outcomes exacerbations requiring oral corticosteroid ocs evidence low low quality asthma control evidence low moderate quality secondary outcomes unscheduled visits evidence low moderate quality quality life evidence low moderate quality however individual studies reported observed benefits ocs use healthcare services school work absence data skewed difficult interpret evidence low quality graded studies specifically measure report adverse eventsstudies investigating possible benefit administering ics school measure adherence exacerbations requiring ocs asthma control adverse events one study showed fewer unscheduled visits another found differences data could combinedpooled results suggest variety interventions improve adherence clinical relevance improvement highlighted uncertain inconsistent impact clinical outcomes quality life asthma control less clear low moderate confidence findings owing concerns risk bias inconsistency future studies would benefit predefining evidencebased cutoff acceptable adherence using objective adherence measures validated tools questionnaires possible covert monitoring form blinding active control may help disentangle effects intervention effects inclusion adherence trial