Supported asthma self-management
Self-management is defined by the US Institute of Medicine as “the tasks that individuals must undertake to live with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management and emotional management of their conditions”. 1
Successful implementation of self-management requires identification of the key components for the individual and the condition being managed.2 In the case of asthma, due to its variable nature over time, individuals need the ability and confidence to “deal with medical management” quickly and appropriately.1 Being able to regain control in the event of an exacerbation is a priority; aiming to prevent potentially severe – and occasionally fatal – exacerbations and hospital admissions.
It is however, important to recognise that individuals are living with asthma full time and, all to a lesser or greater extent monitor and manage their condition in ways that have been shaped over time and informed by advice from different sources. So the comparatively short sessions with a health professional should aim to improve patients’ self-management by valuing what is already being completed well, offering ideas and solutions for improvement, structuring their actions in response to deterioration and providing flexible access to support as necessary.
Supported self-management is highlighted as a key clinical recommendation that should be prioritised for implementation by the BTS-SIGN 2014 asthma guideline.3 A whole chapter of the guideline is dedicated to self-management, providing a clear summary of the evidence and the important recommendations.3 Based on the guidelines, this module offers a case based learning approach to supported self-management with the following learning objectives. After completing the module you should:
- Understand the key components of providing supported asthma self-management
- Appreciate the benefits of self-management to individuals and the health care service
- Be confident in completing a personal asthma action plan and personalising to individuals
- Understand the importance of tailoring self-management support for different cultural, ethnic and age groups.
Dr Luke Daines is a practising GP in Edinburgh. He is part of the Asthma UK Centre for Applied Research with a current focus on Asthma supported self-management.
Professor Hilary Pinnock, Professor of Primary Care Respiratory Medicine, Asthma UK Centre for Applied Research, Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics. Hilary is also a practising GP in Kent.
|List of abbreviations|
|A&E||Accident and Emergency||MART||Maintenance and Reliever Therapy|
|PEF||Peak Expiratory Flow||SABA||Short Acting Beta Agonist|
|PAAP||Personal Asthma Action Plan||LABA||Long Acting Beta Agonist|
|SiT||Single Inhaler Therapy||ICS||Inhaled Corticosteroids|
Mary, a 32 year old business woman, attends the practice several weeks after a hospital admission for an asthma exacerbation. She had been away for a weekend with friends to stay in a farm cottage. Over the weekend she felt her breathing becoming more difficult, and her chest increasingly tight. She had both her preventer and reliever inhalers with her, yet despite her increased use of salbutamol she felt worse and her worried friends took her to the local Accident & Emergency (A&E). Requiring only a short admission, she was dismayed that it took a further week before she had recovered enough to return to work.
She describes her asthma control as generally good, needing to use her reliever very rarely since she started using her preventer regularly 5 years ago. She has previously had one severe asthma attack when horse riding as a young teenager and was admitted to hospital for several days. The recent exacerbation has shocked her, as she felt very much out of control, and didn’t know what to do. She is also concerned about her absence from work. She is keen to do anything possible to help manage her asthma. She has read about supported self-management on the Asthma UK website but doesn’t really understand what it means or if it would really make a difference.
What are the benefits of supported self-management?
The evidence that supported self-management reduces hospitalisations, A&E attendances and unscheduled consultations is overwhelming.4 5 The landmark paper by Gibson et al., a systematic review with meta-analysis of 6090 adults, compared self-management programmes against usual care4. Statistically significant reductions in hospital admissions, A&E visits and same day consultations were found in the self-management intervention groups compared to those who received usual care.4
Furthermore, reduction in asthma symptoms and absenteeism from school or work have been demonstrated in participants receiving self-management interventions.4 6 7 Many, but not all, studies report improved quality of life – a much broader outcome than asthma control.8 9 Benefits have been demonstrated for individuals of all ages (except pre-school children), across primary and secondary care and for patients with mild, moderate and severe forms of asthma.6 10 11 12
Having been forced to take a week off work at a crucial time, Mary is encouraged by the thought of self-management reducing asthma-related days of absence. However she is really busy and not sure she has time to attend a clinic to learn about self-management. She also feels that she already keeps an eye on her symptoms and knew she needed to get to A&E so wonders what else could be done.
What are the key features of supported self-management?
At its optimum, asthma self-management should include education about self-monitoring of symptoms or peak expiratory flow, regular medical review (at a frequency appropriate to the clinical context) and a personal asthma action plan.4 Education should be patient-centred and tailored to the individual’s understanding, encompassing topics such as: recognising and responding to worsening asthma control, identifying and avoiding individual triggers, peak expiratory flow monitoring (if preferred) and inhaler use. Professional review by a doctor or nurse with expertise in asthma management should be at least annual, though may be more regular according to individual patient needs, specifically including early follow up of an exacerbation. In most cases core self-management education would be achievable in a single dedicated session, but reinforcing the action plan and refining the self-management skills is part of on-going support.
Whilst Mary is already aware of her asthma and responding to changes in her condition, an action plan and surrounding discussion would help her to have a clearer idea of when and how to respond to worsening asthma – including when to seek professional help because self management is insufficient. Although good examples of self-management information and personalised asthma action plans exist and are widely available (see Asthma UK), there is no absolute requirement to use a standardised plan. More important is flexibility: providing a personalised set of instructions addressing the needs of an individual in a format that is convenient to them. Similarly, flexible access to information and professional support enables individuals to seek advice about self-management at a time that suits them.
A 22 year old man with a history of asthma attends the practice complaining of cough, a streaming nose, watery eyes, feeling tight chested and short of breath when walking strenuously. He returned home yesterday after 5 days working as a ball spotter at a professional golf tournament. Having to search often in the long grasses of the rough, he had become aware of his chest early in the tournament.
He says he has been using his brown inhaler regularly. Over the last few days he has used his blue inhaler frequently until it ran out. He also bought some over-the-counter anti-histamines which “helped a bit”. On returning to his parents’ home his mother was worried about him and made a same-day appointment for him with his GP.
He is a non-smoker, and apart from mild eczema has no other medical history.
Appears slightly breathless but able to complete sentences when talking.
Heart Rate: 90. Oxygen levels breathing room air: 97%. Respiratory rate 22/minute.
Auscultation of chest: scattered wheeze, no focal sounds, air entry heard throughout.
Peak expiratory flow (PEF) 420. (His personal best PEF, recorded at an asthma review 3 years ago, is 600 l/min)
How would you manage John (in the short and longer term)?
John does not have any features of a severe or life threatening asthma attack, so treating for a moderate exacerbation within the community would be appropriate. Information on treating acute asthma is available in the BTS SIGN 2014 guideline available here and will not be discussed further in this module.
Whilst the most pressing element in this scenario is to treat the acute attack, in the longer term helping John to self-manage his asthma will help prevent future exacerbations.6 A follow up appointment once the exacerbation has been treated is therefore a priority. Providing sufficient medication is of course important, though it would probably be unwise to put medications on a repeat list until a review has been completed and the optimal treatment regime determined. Finally, whilst not an immediate priority, it would be beneficial to optimise management of hay fever given that his current attack was most likely related to grass pollen. Discussion of trigger avoidance, nasal steroids for his hay fever, and considering an increase in inhaled steroids to prevent asthma during periods of increased exposure to pollen.
Adherence to maintenance asthma treatment is often poor. One study based on UK medical records estimated that less than half of patients receiving a prescription were taking their inhaled steroids regularly.13 Addressing non-adherence is challenging as causes are typically multifactorial. Individuals may have decided not to take recommended treatment after considering the risks and benefits from the perspective of their beliefs, the impact of their symptoms and experience of side-effects (intentional non-adherence).14 Simply forgetting, being unable to afford treatment or misunderstanding aspects of the prescribed medicine can also lead to non-adherence (non-intentional).15 Whilst the use of an action plan following discussion cannot guarantee adherence, it may contribute to an improvement through better understanding of the roles of different inhalers and reminding patients how and when to use them.
You review John several weeks later. He has fully recovered from his exacerbation and continues with his regular treatment. You understand that, having completed his computer science degree three months ago he returned to his family home and has re-registered at the practice.
The record from his university practice shows he has received an inhaled corticosteroid twice in the past 6 months with an average of 12 reliever inhalers every year. An asthma review was coded 3 years ago when he enrolled at university, but he hasn’t had time since. He feels his asthma has been controlled well enough with his current treatment, though he does admit to days when he feels limited by symptoms.
You introduce him to the idea of a personal asthma action plan. He wonders what a piece of paper with instructions will do to help his asthma that he thought he was coping with quite well.
Which of the following statements about personal asthma action plans are true?
Action plans are designed to facilitate discussion between patient and practitioner and are accordingly evolving documents that should be regularly reviewed and updated. An action plan is designed to prompt the user to recognise symptoms and/or PEF decline early, potentially 5-10 days before the onset of an exacerbation,16 when appropriate action may abort the attack.
There is no conclusive evidence to favour self-monitoring based on peak flow results over symptoms; both are effective in adults.10 11 17 However in practice few people would monitor peak flows regularly, and therefore both can be used in tandem by including symptoms that should trigger action, as well as peak flow thresholds so that those wishing to check objectively can do so before commencing treatment. One exception may be the sub-group of patients with low symptom and broncho-constriction perception in which PEF based monitoring would be advisable.
A high quality review reported that action plans were most effective when offering 2, 3 or 4 action points, and when they included instructions on increasing inhaled corticosteroids and starting oral corticosteroids.11 However, in children short term increases in inhaled corticosteroids aren’t recommended for treating acute symptoms so instruction about starting regular SABA for a defined period would be an alternative action point in the event of worsening symptoms.3 A good example of a suitable plan is provided by Asthma UK and may be downloaded here
Figure 1 Example of a personal asthma action plan from Asthma UK
As well as providing a written record of an individual’s usual treatment, the action plan should detail the common symptoms associated with a worsening of asthma control. Therefore, completing an action plan in partnership with a patient provides a great opportunity for educating and explaining how to monitor and treat worsening asthma.
If the action plan also uses PEF measurements to guide treatment (as in the example) thresholds for action points should be based on the individual’s personal best.11 Widely accepted thresholds for treatment are a fall in peak flow to 80% of personal best for increasing inhaled steroids and 60% of best for starting an emergency course of steroids. Recommendation to seek urgent clinical advice is based on severity of symptoms and a fall in PEF below 50% of personal best.
Traditional advice when increasing the dose of inhaled corticosteroids has been to double the existing dosage until symptoms have improved or PEF is back to normal range. However there is evidence to suggest that doubling is not enough and rather increasing to a ‘high dose’ (800-1000 micrograms of beclomethasone or equivalent) is needed.18 19 This is only applicable to people prescribed (or actually taking) relatively low maintenance doses (say 400 micrograms of beclomethasone or equivalent). People on high doses will need to move direct to the oral steroid step.
Whilst there are key components to an action plan, to maximise the benefit for an individual, completion of the plan and surrounding discussion should be patient centred and flexible to their concerns and expectations, tailored to the degree of autonomy with which they feel comfortable. For instance some patients may not feel comfortable having an emergency supply of oral corticosteroids at home, preferring first to discuss with a clinician.
Patients using Single inhaler Therapy (SiT) offer a further example where a uniquely tailored action plan is essential. SiT describes the use of a single corticosteroid / long acting beta agonist combination inhaler used as both Maintenance and Reliever Therapy (MART). SiT can be considered for “selected adult patients at step 3 [of treatment] who are poorly controlled” according to the BTS-SIGN 2014 asthma guideline.3 In comparison to fixed dose combination inhalers, SiT reduces the number of asthma exacerbations requiring oral corticosteroids.20 SiT is currently only applicable for combination inhalers using formoterol (as opposed to salmeterol), because formoterol’s onset of action is comparable to salbutamol. Accordingly an action plan for someone using SiT needs to be very specific to their therapy, describing the regular dose for maintenance, worsening asthma control and when further help should be sought.
Whilst agreeing that a personalised guide for managing his asthma would be helpful, John isn’t impressed at the thought of having to carry a piece of paper round with him everywhere. He wonders if there are any other options, perhaps even an APP!
Telehealthcare offers promise for asthma self-management but still requires refinement. Recent systematic reviews of self-management programmes delivered through SMS, smartphone APPs, computers or the internet are cautious in their conclusions; finding no consistent supporting evidence to recommend their general use.21 22 23 24 A further problem is that, of the existing APPs (as of March 2016) none are actually action plans; they are monitoring devices, with links to relevant information in some instances, but with no recommended action points.25
In keeping with a rapidly developing field, the 2016 revision of the BTS-SIGN guideline recommends technology as an alternative approach to delivering care, but not a solution in all instances.19 Overall, clinical outcomes using telehealthcare were felt to be as good as traditional care, but not consistently better.19 So, for now, IT based approaches may be considered in certain circumstances, or according to the preference of patient and clinician.19 A reliable and straightforward method meantime is to take and keep an image of the paper action plan on a phone, as recommended by Asthma UK.26
Mrs Cameron brings her 9 year old son Lawrence to see you on a busy Monday morning. She has been really worried about him over the weekend as he has been full of cold and quite ‘wheezy’. Lawrence was diagnosed with asthma 7 months ago and started on a regular preventer as well as a reliever inhaler that he takes through an aero chamber. His medication list shows three courses of oral corticosteroids in the past 4 months. The reliever inhaler has been issued 10 times in the past 6 months.
The diagnosis of asthma and initial management is detailed in a letter from the local hospital, who had followed him up once after a first presentation with acute asthma. There are several subsequent letters recording attendance at A&E, reporting mild exacerbations with quick recovery from inhaler use only.
You understand Mrs Cameron has changed all the flooring at home from carpet to wooden veneer, bought new hypoallergenic bedding and is meticulous in her cleaning and hoovering. She has tried “everything” to help Lawrence stay well. Today Mrs Cameron is really concerned that Lawrence’s asthma is bad again, and wonders whether steroid tablets would help him get better, as they had an amazing effect before.
Assessment of Lawrence is very reassuring with normal observations. He is coryzal but there are no concerning features on respiratory exam (and no audible wheeze), and his PEF is at his personal best value. You feel it is most likely that he has an uncomplicated upper respiratory tract infection (URTI).
How would you manage Lawrence (and Mrs Cameron) in the short and long term?
This case aims to highlight an anxious parent who is feeling uncomfortable with the recent diagnosis of asthma in her son. Mrs Cameron and her son would particularly benefit from the supported aspect of self-management, so reassurance without any follow up is an incorrect choice. Similarly the further use of oral corticosteroids would be hard to justify based on the current clinical picture together with recent prescriptions. Engaging the family and providing continuity would be a priority; eliciting their ideas and concerns will be crucial in tailoring the approach to their needs.
Supported self-management is effective for children with asthma, reducing acute care visits and hospital admissions, whilst improving control of symptoms.5 12 Personalised action plans for children commonly use both symptoms and peak expiratory flow, with evidence that symptom based plans may be more beneficial in reducing unscheduled healthcare appointments, though peak flow based plans improve the number of symptom free days.5 12 Pre-school children are the only age group in which traditional action plans have been shown to be ineffective, which may be due in part to the overlap with viral induced wheeze in this age group.27
Whilst this example focussed on children, the importance of tailoring supported self-management to cultural and ethnic groups has consistently been identified in systematic reviews.7 28 Simply translating a programme designed for one group of people to another is insufficient. Successful strategies have included reference to appropriate role models and involvement of local community health workers, using asthma educators fluent in community languages and providing purposefully designed materials with ethnically appropriate graphics, respecting and including culturally specific beliefs and practices.3
On returning for review, conversation turns to school. Since being diagnosed with asthma Mrs Cameron has kept Lawrence off school at the first sign of respiratory symptoms. She is worried that the teachers wouldn’t know what to do if his asthma becomes worse, even though she has provided school with spares of his reliever inhaler. The school have also been in touch recently about his frequent absences which is adding to her stress.
Children with asthma have been shown to have poorer attendance at school, with one US study reporting approximately 1.5 extra days of absence per year in comparison to their peers.29 Children and their families who used personal asthma action plans have been shown to have less days of school absence compared to those who had no plan.6 As well as being helpful for families, a copy of a written plan can also be held within the school, allowing the personalised instructions for an individual to be available for school staff. In fact, Asthma UK have a specific school asthma card available to facilitate a central asthma register to be kept at school, available on their website.26 Overall, school-based self-management interventions have been valuable for raising awareness amongst children with asthma and the wider school population.30
Wheeze triggered by exercise should not prevent a child from completing a particular activity. Using a single dose of short acting beta agonist prior to exercise is safe and effective in limiting symptoms of exercise induced asthma. Exercise related symptoms, however, may indicate a lack of asthma control, and should lead to reassessment and review of regular inhaled corticosteroid treatment.3 In the case of an asthma attack, recent changes in legislation mean that a trained member of school staff can administer a rescue dose of a short acting beta agonist from an emergency inhaler.32
- Adams K, Greiner AC and Corrigan JM (eds) The 1st annual crossing the quality chasm summit – a focus on communities. Washington, D.C: The National Academic Press, 2004.
- Pearce G, Parke HL, Pinnock H, Epiphaniou E, Bourne CL, Sheikh A, Taylor SJ. The PRISMS taxonomy of self-management support: derivation of a novel taxonomy and initial testing of its utility. J Health Serv Res Policy 2016 21: 73-82
- British Thoracic Society/Scottish Intercollegiate Guideline Network. British Guideline on the Management of Asthma. 2014 update. http://sign.ac.uk/guidelines/fulltext/141/index.html. Accessed 7 March 2016.
- Gibson PG, Powell H, Wilson A, Abramson MJ, Haywood P, Bauman A, Hensley MJ, Walters EH, Roberts JJL. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2002; Issue 3, Art No. CD001117. DOI: 10.1002/14651858.CD001117.
- Taylor SJC, Pinnock H, Epiphaniou E, Pearce G, Parke H. A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions. (PRISMS Practical Systematic Review of Self-Management Support for long-term conditions) Health Serv Deliv Res 2014; 2:54
- Zemek RL, Bhogal SK, Ducharme FM. Systematic Review of Randomized Controlled Trials Examining Written Action Plans in Children. What Is the Plan? Arch Pediatr Adolesc Med 2008; 162:157-163.
- Bravata DM, Gienger AL, Holty JE, Sundaram V, Khazeni N, Wise PH, McDonald KM, Owens DK. Quality improvement strategies for children with asthma: a systematic review. Arch Pediatr Adolesc Med 2009; 163: 572-581.
- Bailey EJ, Cates CJ, Kruske SG, Morris PS, Brown N, Chang AB. Culture-specific programs for children and adults from minority groups who have asthma. Cochrane Database Syst Rev 2009; Issue 2, Art No. CD006580. DOI: 10.1002/14651858.CD006580.pub4.
- Welsh EJ, Hasan M, Li P. Home-based educational interventions for children with asthma. Cochrane Database Syst Rev 2011; Issue 10, Art No. CD008469. DOI: 10.1002/14651858.CD008469.pub2.
- Powell H, Gibson PG. Options for self-management education for adults with asthma. Cochrane Database Syst Rev 2002; Issue 3, Art No. CD004107. DOI: 10.1002/14651858.CD004107
- Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components Thorax 2004; 59: 94–99. doi: 10.1136/thorax.2003.011858
- Bhogal SK, Zemek RL, Ducharme F. Written action plans for asthma in children. Cochrane Database Syst Rev 2006; Issue 3, Art No. CD005306. DOI: 10.1002/14651858.CD005306.pub2.
- Van Staa TP, Cooper C, Leufkens HG, Lammers JW, Suissa S. The use of inhaled corticosteroids in the United Kingdom and the Netherlands. Respiratory medicine. 2003; 97(5): 578-85.
- Horne R. Compliance, adherence, and concordance: implications for asthma treatment. Chest2006; 130: Suppl. 1, 65S–72S.
- Nunes V, Neilson J, O’Flynn N, Calvert N, Kuntze S, Smithson H, Benson J, Blair J, Bowser A, Clyne W and Crome P. Medicines Adherence: involving patients in decisions about prescribed medicines and supporting adherence. London, National Collaborating Centre for Primary Care and Royal College of General Practitioners, 2009.
- Honkoop PJ, Taylor DR, Smith AD, Snoeck-Stroband JB, Sont JK. Early detection of asthma exacerbations by using action points in self-management plans. European Respiratory Journal. 2013. 41(1): 53-9.
- Toelle B, Ram FSF. Written individualised management plans for asthma in children and adults. Cochrane Database Syst Rev 2004; Issue 1, Art No. CD002171. DOI: 10.1002/14651858.CD002171.pub2.
- Harrison, T. W., Oborne, J., Newton, S., & Tattersfield, A. E. Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial. Lancet 2004; 363: 271-275.
- British Thoracic Society/Scottish Intercollegiate Guideline Network. British Guideline on the Management of Asthma. 2016 update. http://www.sign.ac.uk/pdf/Asthma_2016_consultation%20_draft.pdf Accessed 26 March 2016.
- Kew KM, Karner C, Mindus SM, Ferrara G. Combination formoterol and budesonide as maintenance and reliever therapy versus combination inhaler maintenance for chronic asthma in adults and children. Cochrane Database Syst Rev 2013 Issue 12.
- De Jongh T, Gurol‐Urganci I, Vodopivec‐Jamsek V, Car J, Atun R. Mobile phone messaging for facilitating self‐management of long‐term illnesses. Cochrane Database of Syst Rev 2012 Issue12
- Marcano Belisario JS, Huckvale K, Greenfield G, Car J, Gunn LH. Smartphone and tablet self management apps for asthma. Cochrane Database of Syst Rev 2013 Issue 11.
- Bussey-Smith KL, Rossen RD. A systematic review of randomized control trials evaluating the effectiveness of interactive computerized asthma patient education programs. Ann Allergy Asthma Immunol 2007; 98: 507–516.
- Stinson J, Wilson R, Gill N, Yamada J, Holt J. A systematic review of internet-based self-management interventions for youth with health conditions. Journal of pediatric psychology 2009 34 (5), 495-510.
- Huckvale K, Car M, Morrison C, Car J. Apps for asthma self-management: a systematic assessment of content and tools. BMC medicine 2012 10(1): 1.
- Asthma UK website [https://www.asthma.org.uk/advice/manage-your-asthma/action-plan/] Accessed 22nd February 2016.
- Stevens CA, Wesseldine LJ, Couriel JM, Dyer AJ, Osman LM, Silverman M. Parental education and guided self-management of asthma and wheezing in the pre-school child: a randomised controlled trial. Thorax 2002; 57(1): 39-44.
- Boyd M, Lasserson TJ, McKean MC, Gibson PG, Ducharme FM, Haby M. Interventions for educating children who are at risk of asthma-related emergency department attendance. Cochrane Database Syst Rev 2009; Issue 2, Art No.CD001290. DOI: 10.1002/14651858.CD001290.pub2.
- Moonie SA, Sterling DA, Figgs L, CastroM. Asthma status and severity affects missed school days. Journal of School Health 2006; 76 (1): 18–24.
- Coffman JM, Cabana MD, Yelin EH. Do School-Based Asthma Education Programs Improve Self-Management and Health Outcomes? Pediatrics 2009; 124 (2): 729–742. doi:10.1542/peds.2008-2085.
- Bonini M, Di Mambro C, Calderon MA, Compalati E, Schünemann H, Durham S, Canonica GW. Beta2-agonists for exercise-induced asthma. Cochrane Database Syst Rev 2013; 10.
- Department of Health. Emergency asthma inhalers for use in schools. Accessed 11 March 2016. https://www.gov.uk/government/publications/emergency-asthma-inhalers-for-use-in-schools
- Panagioti M, Richardson G, Murray E, Rogers A, Kennedy A, Newman S, et al. Reducing Care Utilisation through Self-management Interventions (RECURSIVE): a systematic review and meta-analysis. Health Serv Deliv Res 2014; 2 (54).
- Levy M, Andrews R, Buckingham R, Evans H, Francis C, Houston R, Lowe D, Nasser S, Pation J, Puri N, Stewart K. “Why asthma still kills: The national review of asthma deaths (NRAD) confidential enquiry report.” Royal College of Physicians, 2014.
- Ring N, Malcolm C, Wyke S, MacGillivray S, Dixon D, Hoskins G, Pinnock H, Sheikh A. Promoting the use of Personal Asthma Action Plans: a systematic review. Prim Care Respir J 2007; 16(5): 271-83.
- Kemple T, Rogers CA. Mailed personalised self-management plan improves attendance and increases patients’ understanding of asthma. Prim Care Respir J 2003; 12(4): 110-4.
- Pinnock H, Epiphaniou E, Pearce G, Parke H, Greenhalgh T, Sheikh A, Griffiths CJ, Taylor SJ. Implementing supported self-management for asthma: a systematic review and suggested hierarchy of evidence of implementation studies. BMC Medicine 2015; 13(1): 1.
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