Thirty-six studies (108,367, range 24 to 101,368) met the inclusion criteria. Fourteen studies had good methodological quality (≥70 points) and 22 were moderate quality (50 to 69 points). Twenty-eight of the studies were RCTs and eight were controlled before-after studies. Eighteen of the 36 studies identified as multiple intervention studies focused on COPD, 16 focused on asthma and two on both asthma and COPD.
Patient education combined with case management compared to usual care (nine studies) showed mixed results. There was no significant difference between the intervention and control in lung function, symptoms scores or emergency department visits. Triple interventions were significantly more effective than usual care on total quality of life (WMD -4.59, 95% CI -8.34 to -0.83; three studies; 313 patients), activity (WMD -5.20, 95% CI -9.76 to -0.64; three studies; 320 patients) and impact (WMD -4.41, 95% CI -8.19 to -0.62; three studies; 313 patients). Multiple interventions led to a decrease in hospital admissions compared with usual care (WMD 0.58, 95% CI 0.40 to 0.83; five studies; 634 patients). Double interventions did not demonstrate any significant impact compared to usual care.
Patient education combined with revision of professional roles and professional education (six studies) showed that substitution of physicians by nurses was not associated with significant benefits, except process improvement (mostly inhalation technique) showed improvement (three studies). For studies that compared pharmacist provision of drug counselling that was formerly provided by nurses and physicians, double interventions showed significant improvement on quality of life when compared with usual care (WMD 0.72, 95% CI 0.47 to 0.96; two studies; 324 patients), but not triple interventions (two studies; 517 patients).
Four of the five studies that assessed multiple intervention versus single intervention and reported quality of life demonstrated a non-significant benefit with multiple interventions. Data on other outcomes were synthesised because they were too diverse.