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Structured Abstract
Objectives:
This review evaluates the effectiveness of allergen reduction interventions on asthma outcomes in adults and children.
Data sources:
We systematically searched the gray literature and five bibliographic databases, MEDLINE®, Embase®, PubMed®, CINAHL®, and the Cochrane Library, through April 21, 2017.
Review methods:
Eligible studies included systematic reviews, meta-analyses, randomized controlled trials (RCTs), and nonrandomized controlled interventional studies. Studies were evaluated for risk of bias using the Cochrane Risk of Bias instrument or the Newcastle-Ottawa scale, and the evidence base was assessed using the methods guidance established by the Evidence-based Practice Center Program. Qualitative comparative analysis was conducted to support the primary analysis.
Results:
Our literature searches identified 72 publications describing interventions to reduce exposure to indoor allergens and their effects on asthma. This included 60 unique RCTs with data published in 64 articles, as well as 8 non-RCTs. Validated measures of asthma control were infrequently reported across studies, and findings were often inconclusive. Thirty-eight studies evaluated single component interventions. Use of acaricides (dust mite pesticides) was not shown to improve pulmonary function (moderate strength of evidence [SOE]). Air purification devices, used alone, improved quality of life (low SOE) but did not reduce exacerbations or health care utilization (low SOE) or improve pulmonary function (low SOE). Impermeable mattress covers were not associated with improved asthma control (moderate SOE) and did not reduce exacerbations or health care utilization (moderate SOE) or improve quality of life (high SOE). Single intervention studies did not adequately examine carpet removal, high-efficiency particulate air-filtration (HEPA) vacuums, mold removal, pet removal, and pest control.
Thirty studies assessed multicomponent interventions, but wide differences among study interventions (and combinations of interventions) precluded meta-analysis. When examined as a component within a broader set of interventions, use of air purification reduced school absenteeism (low SOE) but did not improve asthma control (low SOE), reduce exacerbations (high SOE), or improve quality of life (high SOE). HEPA vacuums, when included in a multicomponent approach, reduced exacerbations and improved quality of life (moderate SOE) for children. Mattress covers used within multicomponent interventions reduced school absenteeism and missed activities (low SOE) but had no effect on emergency department visits (low SOE), hospitalizations (high SOE), or quality of life (moderate SOE). Pest control strategies incorporated into multicomponent interventions reduced exacerbations (moderate SOE), improved quality of life (low SOE), and reduced school absenteeism (low SOE) but did not reduce emergency department visits (moderate SOE), hospitalizations (high SOE), or worker absenteeism (low SOE). Other multicomponent interventions included carpet, mold, and pet removal, but the evidence for these strategies was inconclusive.
Conclusions:
Single intervention studies were not associated with improvement in clinical asthma outcomes, with most strategies showing inconclusive results or no effect. Multicomponent intervention studies demonstrated improvement in various outcomes, but no specific combination of interventions was identified as more effective than others. High or moderate strength evidence suggests that multicomponent interventions that include HEPA vacuums or pest control may be effective in reducing exacerbations and improving quality of life. For many primary outcomes for both single and multicomponent interventions, the evidence is inconclusive because of a lack of studies. Further research is needed examining well-defined (standardized) indoor allergen reduction interventions in comparative studies, with sufficient population size of well-characterized patients to detect clinically meaningful differences in validated and relevant asthma outcomes.
Contents
- Key Messages
- Preface
- Acknowledgments
- Technical Expert Panel
- Peer Reviewers
- Evidence Summary
- Introduction
- Methods
- Results
- Discussion
- References
- Abbreviations and Acronyms
- Appendix A. Search Strategies
- Appendix B. Excluded Studies
- Appendix C. Evidence Tables
- Appendix D. Qualitative Comparative Analysis
- Appendix E. Minimally Important Differences
Suggested citation:
Leas BF, D’Anci KE, Apter AJ, Bryant-Stephens T, Schoelles K, Umscheid CA. Effectiveness of Indoor Allergen Reduction in Management of Asthma. Comparative Effectiveness Review No. 201. (Prepared by the ECRI Institute–Penn Medicine Evidence-based Practice Center under Contract No. 290-2015-0005-I.) AHRQ Publication No. 18-EHC002-EF. Rockville, MD: Agency for Healthcare Research and Quality; February 2018. Posted final reports are located on the Effective Health Care Program search page. DOI: http://doi.org/10.23970/AHRQEPCCER201.
This report is based on research conducted by the ECRI Institute–Penn Medicine Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00005-I). The National Institutes of Health (NIH) National Heart, Lung, and Blood Institute (NHLBI) sponsored the report. The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ or NIH/NHLBI. Therefore, no statement in this report should be construed as an official position of AHRQ, NIH/NHLBI, or the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.
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Mr. Leas and Dr. D’Anci contributed equally to this report.
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