Delivery of supported self‐management in remote asthma reviews: A systematic rapid realist review

Abstract Background The COVID‐19 pandemic forced health care systems globally to adapt quickly to remote modes of health care delivery, including for routine asthma reviews. A core component of asthma care is supporting self‐management, a guideline‐recommended intervention that reduces the risk of acute attacks, and improves asthma control and quality of life. Objective We aimed to explore context and mechanisms for the outcomes of clinical effectiveness, acceptability and safety of supported self‐management delivery within remote asthma consultations. Design The review followed standard methodology for rapid realist reviews. An External Reference Group (ERG) provided expert advice and guidance throughout the study. We systematically searched four electronic databases and, with ERG advice, selected 18 papers that explored self‐management delivery during routine asthma reviews. Setting, Participants and Intervention Health care professional delivery of supported self‐management for asthma patients during remote (specifically including telephone and video) consultations. Main Outcome Measures Data were extracted using Context‐Mechanism‐Outcome (C‐M‐O) configurations and synthesised into overarching themes using the PRISMS taxonomy of supported self‐management as a framework to structure the findings. Results The review findings identified how support for self‐management delivered remotely was acceptable (often more acceptable than in‐person consultations), and was a safe and effective alternative to face‐to‐face reviews. In addition, remote delivery of supported self‐management was associated with; increased patient convenience, improved access to and attendance at remote reviews, and offered continuity of care. Discussion Remote delivery of supported self‐management for asthma was generally found to be clinically effective, acceptable, and safe with the added advantage of increasing accessibility. Remote reviews could provide the core content of an asthma review, including remote completion of asthma action plans. Conclusion Our findings support the option of remote delivery of routine asthma care for those who have this preference, and offer healthcare professionals guidance on embedding supported self‐management into remote asthma reviews. Patient and Public Contribution Patient and public contribution was provided by a representative of the Asthma UK Centre for Applied Research (AUKCAR) patient and public involvement (PPI) group. The PPI representative reviewed the findings, and feedback and comments were considered. This lead to further interpretations of the data which were included in the final manuscript.


| INTRODUCTION
There are 339 million people living with asthma worldwide. 1 Asthma is a variable condition and evidence-based guidelines (e.g., GINA 2 ; BTS/SIGN 3 ) highlight the importance of supporting people to recognize when their condition is deteriorating and to know how to adjust their treatment and/or seek medical advice in a timely and effective manner. Supported self-management is an approach that facilitates patients with long-term conditions (LTCs; such as asthma) to have the knowledge, skills, and confidence to manage the physical, emotional and social impact of their condition(s). 4 The 'overwhelming' conclusion of evidence syntheses is that supported self-management for asthma improves asthma control, reduces exacerbations and hospital admissions, and improves patients' quality of life. 5,6 Despite this robust evidence, implementation in routine clinical care is challenging. 7 Remote consulting, already promoted as a partial solution to growing challenges of healthcare delivery, was rapidly expanded in response to the worldwide COVID-19 pandemic. 8 Within the United Kingdom general primary care, there was a dramatic shift away from face-to-face consultations to telephone, video and on-line consultations. 9 In the months following UK COVID-19 lockdown in early 2020, only 11% of primary care general practice appointments were conducted face-to-face, suggesting that nearly 90% of patientprovider interactions took place via remote means. 10 Remote consultations can potentially provide both benefits and challenges for patients and health professionals. Suggested advantages of remote consulting include improving access to care for LTCs, 11 maximizing the potential for supporting self-management, 12 overall acceptability, safety and effectiveness 13,14 and improvements in asthma control. 15,16 However,critics have raised concerns about the use of remote delivery of routine primary care due to variable evidence of suitability and the associated technical, clinical and organisational policy challenges. 17

| Rationale for review
Published research regarding the delivery of supported selfmanagement during remote asthma consultations is sparse and the speed of technological advance means it needs frequent updating. Given the changing clinical context and national/ international recommendations for implementing supported selfmanagement, 2,3 providing guidance on this new approach to delivery is timely. Informing a UK-wide cluster randomized controlled trial, evaluating the implementation of supported selfmanagement (IMPlementing IMProved Asthma self-management as RouTine [IMP 2 ART]), this study uses a rapid realist review approach [18][19][20][21] to explore the clinically effective, safe and acceptable delivery of supported self-management of asthma via remote routine reviews. Conducting a rapid realist review will enable understanding not only about whether an intervention/ approach works but how and in what clinical, demographic or organisational context.

| Study objectives
Using realist methodology, we aimed to: 1. Identify and synthesize studies that evaluated and/or explored remote asthma consultations and the delivery of supported selfmanagement.
2. Explore the context and mechanisms that have contributed to clinically effective, safe and acceptable delivery of supported selfmanagement during remote asthma consultations.

| Study design
Following Realist Review methodology [18][19][20][21] to identify Context-Mechanism-Outcome (C-M-O) configurations within existing research, our review explored how supported self-management is delivered during routine remote asthma reviews. The study is reported in line with the RAMESES Publication Standards for Realist Synthesis and Realist Reviews. 22 We registered our protocol on the PROSPERO database (Registration No.: CRD42020207543).

| Realist methodology
Devised by Pawson and Tilly,18,20,21 realist methodology is a theorydriven review process that focuses on understanding the interplay of an intervention's Context (C), Mechanisms (M) and Outcomes (O) and whether the intervention works (or not). Conducting realist research aims to answer the question 'what works, for whom, in what contexts, to what extent and most importantly how and why'. 18 Realist methods are increasingly used within healthcare research due to their ability to support the understanding of complex interventions. Within realist methodologies, a programme theory is a specific hypothesis about how an intervention causes the intended or observed outcomes and should be the central aspect of any realist evaluation or synthesis. 23 Several varied theories are identified initially using a broad scope of existing literature to refine the purpose of the review and identify review questions. Programme theory formulation is subsequently an iterative process that progresses as the evidence is identified, assessed and synthesized, until an evidence-based saturation and conclusion have been reached. 20 Pawson differentiates between realist evaluations-an approach used when conducting primary research, and realist synthesis-an approach used to synthesize secondary data. 20

| Rapid realist review
For this review, we used the rapid realist review approach described by Saul et al. 19 (displayed in Figure 1) to apply a realist synthesis approach in a timely manner where there is an emerging evidence base for the subject area under review, while still preserving the core elements of realist methodology. An important feature of a rapid realist review is to engage an External Reference Group of experts, who provide informed direction to the data identification and theory development throughout the entirety of the review, and ensure the review is grounded in the local context. We convened a multidisciplinary External Reference Group, including researchers, clinicians (nurses and GPs) and primary care respiratory experts.
Members met twice during the review process, initially to provide feedback on the project scope and the full-text articles proposed for inclusion. The group met again to review findings from the data extraction and advise on data synthesis.

| Scoping the literature
The review took place between August 2020 and March 2021.
One reviewer (E. K.) initially scoped relevant literature exploring the delivery of routine asthma reviews via remote consultations.
From this initial broad search, the research group created a preliminary programme theory. This process defined the scale of the research and ensured that the review focussed appropriately on the research questions. Although not an essential element of a rapid realist review, the creation of programme theory is a recognized step in realist approaches. [18][19][20][21] We, therefore, decided to adopt this approach within this review: The initial programme theory formed the basis of the iterative data collection, data extraction, data synthesis and subsequent theory development stages, and the concluding programme theory allowed a final statement of the evidence to be produced.

| Search process
The following databases were searched in October 2020 by E. K.: MEDLINE, Embase, PsychINFO and the Cochrane Library. Key search terms that were likely to identify studies relevant to the research questions and to address the purpose of the review were used (File S1). We searched for qualitative, quantitative, mixedmethod studies and grey literature published after 2000, to reflect contemporary remote consultation technologies, and the introduction in the UK of the Quality Outcomes Framework in 2004 (which incentivized regular reviews for LTCs including asthma). 24 Using the PICOS Framework, 25 eligibility criteria were developed (Table 1), and studies that did not meet the inclusion criteria or were not published in the English language were excluded. Consistent with a realist synthesis approach, it was still possible for data beyond this framework to be included in the review if the article contributed to the development of the review's programme theory. Documents were assessed collectively by the study team to determine whether the evidence provided was 'good enough and relevant enough', 21 to inform the creation of appropriate C-M-O configurations within the data. In line with the iterative approaches of realist methodologies, we used snowballing techniques (such as searching companion papers and citation tracking) for all included articles to ensure that important texts were not overlooked. We also searched for additional relevant grey literature (e.g., policy documents, opinion pieces) from a variety of sources (including any suggested by the External Reference Group). The search process was iterative, overlapped with data extraction and analysis, and was directed towards the evidence gaps and finding explanatory information.

| Selection and appraisal of documents
Titles/abstracts and potentially eligible full texts were independently screened by two reviewers (E. K. and I. S.), and disagreements were resolved by discussion.

| Data extraction
To begin the data extraction phase, a template was devised focusing on C-M-O configurations that explored components of support for self-management, as defined by the Practical Systematic Review of Self-Management Support (PRISMS). 26 The PRISMS taxonomy was used as a framework during the data extraction phase by categorizing C-M-Os into one of the 14 components of self-management support, to streamline the subsequent data synthesis processes.
Examples of these components include 'A1. Information about condition and/or its management' and 'A2. Information about available resources'. PRISMS components are further explained within File S2.
The data extraction template also allowed for recording as to whe- (25% was independently extracted by I. S. to ensure consistency of approach, reliability and validity. The independent extraction of data by the two authors (E. K. and I. S.) resulted in the same C-M-O configurations being extracted by both authors, that is, each author identified the same outcome related to remote delivery of SSM in all papers and also connected the same context and mechanism to each outcome for all papers. How to optimally present the data (i.e., which data extract was used) and the interpretation of each C-M-O was discussed in detail until a consensus was reached.

| Analysis and synthesis processes
We used the PRISMS taxonomy 26 to structure our synthesis. The PRISMS meta-review highlighted the importance of supported The rapid realist review approach (adapted from Saul et al.) 19 T A B L E 1 Inclusion and exclusion criteria for the rapid realist review systematic database search, following the PICOS Framework 25

Inclusion Exclusion
Population Adults or children with a diagnosis of asthma Participants with other long-term health conditions (unless the study presented data for people with asthma separately) Healthcare professionals who regularly deliver asthma care Patients receiving care under severe asthma clinics (because they have specialist needs which may be different to the majority of primary care patients)

Intervention
Remote consultations (e.g., telephone/video consultations) Studies that use automated telehealth interventions (e.g., mobile apps or email consultations) and do not include personalized contact with a healthcare professional in real time Includes delivery of supported self-management Interventions targeted at people under a severe asthma clinic

No remote consultation delivery
Comparison Trials that compare remote asthma care consultations versus standard face-to-face (in-person) reviews Trials that do not compare remote asthma care consultations versus standard face-to-face (in-person) reviews Before and after studies, assessing the implementation of remote reviews

Outcomes
Delivery of a standard primary care asthma review Studies that do not present any form of self-management support Study design Quantitative, qualitative and mixed-method studies Studies that do not meet the study design inclusion criteria self-management as a key component of high-quality care for people living with LTCs, concluding that healthcare providers should promote a culture of actively supporting self-management as a routine, expected and monitored aspect of care. 26 Self-management is a broad concept applicable to different demographics of people living with a wide range of LTCs, and thus the support that can be provided is diverse. The use of the PRISMS taxonomy ensured we captured this breadth in a structured way. To

| Study characteristics
All 18 included studies were published between 2003 and 2020 and were undertaken in the United Kingdom (n = 10), the United States of America and Canada (n = 7) and Italy (n = 1). Eight of the included papers were systematic reviews (n = 5) or meta-reviews (n = 3), including data from a total of (n = 366) unique primary studies represented within these systematic reviews. Eleven papers had the primary aim of exploring the use of remote consultations in routine asthma reviews. Of the three papers provided by the External Reference Group, one was a feasibility study and two were systematic reviews. Detailed study characteristics can be found in File S2.

| Main findings
The data extraction process was completed for the 18 included ar-

| Theme 1: Increased regular attendance and increased monitoring of patient
Patients: For patients with asthma, the increase in regular attendance at reviews conducted remotely was due to a number of advantages, including increased convenience, time and cost savings for patients. 14,17,27,29,31,33 Remote reviews were perceived as better at meeting patient needs and preferences compared to a standard faceto-face review, as they reduced barriers to treatment and eased access to routine care. 14,17,27,29,31,32,[34][35][36]39,40 Regular attendance at remote reviews and supported self-management delivery led to an increase in patient confidence and enablement in their asthma care. 33,36 Professionals: Symptoms could be monitored, reviewed, interpreted and acted on safely in remote consultations. Increased patient attendance at routine remote reviews created regular opportunities for healthcare professionals to provide feedback on monitored asthma symptoms to patients (e.g., monitoring peak flows and asthma triggers). 27,28,30,34,38,39 Additionally, the opportunity to maintain contact and ongoing monitoring was one of the most commonly recognized advantages of remote consultations. 27,28,34 Patients' medication and asthma action plans could be reviewed, reinforcing earlier detection of symptoms or deterioration and timely self-management. 38,39 Video consultations: In addition to enabling feedback on monitored asthma symptoms or behaviours, video consultations had particular advantages for monitoring a patient's condition through systems, such as 'document camera' or 'picture-in-picture' functions, which facilitated patients and professionals reviewing the contents of documents (e.g., asthma action plans) together. 27,30 Telephone consultations: A number of articles supported telephone reviews as an efficient way of maintaining contact with asthma patients. 34,39 Telephone consultations facilitated regular discussions and met patients' needs and preferences due to increased convenience, facilitating attendance at routine telephone reviews.

| Theme 2: Opportunities to provide individualized information about asthma and asthma management
Patient: Video and telephone consultations were a safe and effective mechanism to facilitate the delivery of individualized information about asthma and its management, resulting in increased patient understanding of their condition 27 …were more likely to attend their routine asthma review, and attend subsequent routine remote reviews. 14,17,27,[29][30][31][32][33][34]36,39 Healthcare professionals (HCPs) conducting routine asthma reviews… …via telephone/video consultation, with patients regularly attending routine remote reviews… …have more opportunities to monitor a patient and provide regular support for selfmanagement. 27,28,30,34,38,39 People with asthma whose routine review is conducted remotely… …via video consultation… …can have their condition and management successfully monitored, and the use of video can lead to increased patient attendance to regular routine reviews. 27,30 People with asthma, whose routine review is conducted remotely… …via telephone consultation… … can have their condition and management successfully monitored, and the use of the telephone can lead to increased patient attendance to regular routine reviews. 34 People with asthma whose routine review is conducted remotely… …via video consultation with document sharing/ recording functions… …are able to understand and engage in personalized discussions and information regarding their asthma condition and management. 27,31,33,40 People with asthma whose routine review is conducted remotely… …via telephone consultation… …are able to understand and engage in personalized discussions and information regarding their asthma condition and management. [35][36][37]39 3. Provision of convenient/flexible access to advice and support For people with asthma… …the availability of HCPs to conduct remote consultations (video/ telephone consultation)… …can provide patients with a timely and appropriate option to gain advice and support from HCPs regarding their condition. 14,17,27,29,30,33,34,39 HCPs conducting routine asthma reviews… …when delivering review via remote consultation… …can provide more convenient delivery of routine care for patients to access advice and support. 12,27,29,35 People with asthma… … when a routine review is conducted via video consultation or telephone… …may find the mode of consultation delivery more convenient and flexible to fit their everyday lives, resulting in increased and flexible access to advice and support. 34 information to patients. [35][36][37] More specifically, telephone reviews were recognized as a timely, 39 effective and efficient means to provide information and transfer instructions to patients to manage their asthma.

| Theme 3: Provision of convenient/flexible access to advice and support
Patients: Remote consultations provided more convenient and flexible access to advice and support for patients with asthma, compared to attending a face-to-face review. 34,39 Particular groups who favoured the convenience and timeliness of remote consultations were patients who lived in rural communities, 27,30 patients whose lives were structured around work, study or childcare, 17 younger patients who were more familiar with the use of technology 29,33 and older, vulnerable patients with reduced mobility. 14,33 Ease of access was particularly helpful for patients who noticed a change in symptoms or peak flow readings and were able to contact a healthcare professional promptly via remote consultation. 29 Remote asthma consultations may potentially narrow socioeconomic inequalities in access to healthcare, by being more accessible to vulnerable groups. 14,33 Professionals: Healthcare professionals may have more availability to conduct a remote video or telephone review, enabling them to respond more promptly than a face-to-face appointment may have offered. 12,27,29,35 Video and telephone consultations: For some patients, telephone and video consultations were a preferred method of consultation, and patients were more likely to attend this type of review, leading to increased engagement. 34,39 T A B L E 2 (Continued)

Context-Mechanism-Outcomes (C-M-O) configurations
Background information e.g., setting and demographics to outline possible Contextual factors Key workings that contributed to the design and functioning of a pathway to identify Mechanisms and resources

Information and evidence suggestive of the successes or failures of different aspects of an intervention (Outcomes)
When an HCP is conducting a routine remote asthma review… …and there is an existing relationship between patient and professional… …the professional is able to engage the patient in shared decision-making and selfmanagement strategies. 28,30,31,34,37,40 When an asthma patient's review is conducted remotely… …and via video consultation… …collaborative discussions and selfmanagement strategies can be effectively communicated and discussed. 30 HCPs conducting a routine asthma review… …when the review is conducted via remote consultation… …can effectively communicate practical selfmanagement advice (e.g., inhaler technique and action plans) and enable collaborative discussions with patients. 27,39 People with asthma whose review is conducted via video consultation… …when provided with information on practical self-management strategies (asthma action plans/inhaler technique)… …is able to understand and engage in discussions regarding the best use of these tools. 27,39,40 People with asthma whose review is conducted via telephone consultation… …when provided with information on practical self-management strategies… …is able to understand and engage in discussions regarding the best practice of using these tools and then HCP or patient is able to convert the information in written format. 31 17,33 and increased attendance at reviews. 30 Reviews conducted with the same clinician were seen to be particularly important to young people, 33 leading to more engagement and increased confidence in self-management strategies. The mechanism for this was the trust built during an existing relationship between professional and patient .33 Professionals: A number of studies suggested that when a relationship is already established between patient and professional, telephone and video technologies are a suitable platform to engage in shared decision-making and discussion of self-management strategies. The existing relationship ensures the professional recognizes changes in a person's condition due to their prior awareness of personal circumstances. 28,30,31,34,37,40 Video consultation: Patients were able to discuss their asthma action plan with their health professional during remote reviews.
Video-facilitated collaboration through technologies, such as 'screening sharing' and 'editing documents', allowed the patient and professional to work together to personalize their action plan. 30,40 Recording functions enabled patients to revisit their review and help consolidate the information delivered, to improve understanding of their asthma and how to manage their condition. 30 up-to-date strategies to manage their condition. 27,31,33,35,36,38,39,41 Patients also gained confidence to undertake self-management techniques from regularly attending remote reviews, which they may have missed from nonattendance at a face-to-face review.
Overall, this led to increased confidence in their understanding of how to identify impending attacks and in their ability to act appropriately. 12,38

| Overarching synthesis
The overarching synthesis from the six key themes identified that, in relation to the review's key aims (to explore the safety, clinical effectiveness and safety of supported self-management delivery in remote asthma consultations), remote consultations were overall, more highly accepted than in-person consultations by many patients and professionals, and were an equally safe and effective alternative to face-to-face reviews. In only one instance were concerns raised about remote consulting, 29 in particular with regard to clinical effectiveness and safety. Specifically, uncertainties about the effectiveness and quality of interactions compared to face-to-face meetings were raised. One further study 28 suggested there was no perceived improvement of control where telemedicine alone was received, although this is not suggestive of poorer results. An overview of all findings has been presented in Table 3.

| Summary of findings
We identified six themes using data from 18 articles to describe how supported self-management is delivered during remote asthma consultations. We identified positive benefits associated with remote asthma care, including increased convenience, improved access (including for some vulnerable groups) and attendance at reviews, ability to assess the core content of asthma remotely (especially video reviews that enabled practical tasks such as checking inhaler technique), completion of asthma action plans (screen sharing or discussed with documents sent postconsultation) and continuity of care. Typically, these overrode any challenges associated with distance imposed by remote consultations, and patient's concerns about the quality of the interaction. Overall, our data suggest that for many patients and healthcare professionals, remote consultations are more highly accepted than in-person consultations, and were equally as effective and safe as face-to-face reviews.

| Interpretation of findings of this study in relation to current literature
Guidelines for asthma management 2,3 recommend that asthma should be monitored (often in primary care) by routine clinical review on at least an annual basis. Every asthma consultation is an opportunity to review, reinforce and extend patient's knowledge and skills. 5 Regular professional review is a core component of supported self-management, 26 with evidence of greater reductions in hospitalisations and emergency department visits in trials where the intervention includes regular review. 43,44 The findings of this realist review show that using remote means to provide consultations can increase patient engagement and attendance at asthma reviews. 14,17,27,[29][30][31][32][33][34]36,39 Our realist synthesis suggests that one mechanism for the benefits of telehealth communications is the convenience of telephone or video consultations, which facilitates attendance at reviews. 14,17,27,29,30,33,34,39 Providing patients with information and guidance for selfmanagement of their asthma is an essential aspect of all routine reviews. Our findings highlight that the use of telephone and video consultations is an acceptable, effective and safe alternative to faceto-face consultations for providing patients with this information.
Importantly, the partnership between the patient and professional should enable information to be discussed, understood and agreed upon between both the patient and professional. Such 'shared decision-making' can improve clinical outcomes and quality of life by actively engaging them in managing their own health. 45 We found that telephone and video consultations have the potential to be effective platforms that can facilitate shared decision-making.
Asthma is a variable condition and some people with asthma may be well controlled and need very little support for many months.
However, when symptoms are triggered, access to professional care needs to be flexible in timing and mode of delivery. 46 As an alternative to face-to-face consultations, the findings of this study highlight that remote asthma reviews can provide flexible and convenient access to professional support enabling patients to be provided with appropriate and prompt clinical input. Such flexible access to their healthcare professionals promotes patients' confidence in their ability to self-manage their condition. 12,27,31,33,35,36,38,39,41 The provision of a personalized asthma action plan is an essential strategy in supporting people with asthma to take the right actions at the right time. Clinical effectiveness Remote consultations were recognized as clinically effective as providing a face-to-face review concludes that it is critical to plan carefully for the use of remote technologies and to identify the best practice of self-management delivery at scale and in a sustainable way. The findings of our review provide the context and mechanisms for effective remote asthmasupported self-management delivery.

| Strengths and limitations
To our knowledge, we have conducted the first rapid realist review in the area of asthma supported self-management delivery via remote consultation. Our review is timely given the shift to remote care driven by the COVID-19 pandemic, and we explored the (rapidly expanding) use of video and/or telephone consultations, and systematically identified the perceived benefits and challenges of each mode of delivery in relation to each theme. Additionally, the findings are explored through the perspective of both the health professional and the patient. A final strength is that we utilized a robust realist methodology, which is gaining recognition for its contribution to healthcare research. 49 A weakness of our study was the time constraints that we overcame by the use of a rapid realist review. By design, our review was 'rapid', and we recognize that a more detailed approach such as a traditional realist synthesis may have revealed, challenged or confirmed some of the themes presented in the findings of this study, due to its ability to test presented theories. However, we believe our To increase the reliability of findings, we involved a second reviewer in the data extraction phase. The research team regularly discussed potential findings to ensure different perspectives were considered and resulted in a balanced interpretation of the data. The aim was to reach a consensus in interpretation, and this was achieved for all findings.
This review was completed during the COVID-19 pandemic period, but all studies included in the data predated the pandemic.
Post-COVID research may present different findings as healthcare adapts to new models of asthma care. Additionally, we were dependent on the completeness of the included studies, so some potentially important contexts may not have been evaluated.
For example, we did not have evidence to inform the role of remote support for self-management in the context of people living with disabilities, or ethnic minority groups potentially with language barriers. Future research should specifically explore remote supported self-management delivery for such groups.
We also acknowledge that although the review findings indicate either equivalence or greater benefit of remote self-management delivery, there will be individuals for whom face-to-face reviews are a preferred mode of healthcare delivery and communication.
Additionally, we recognize that the 'safety' variable measured within this review has not been tested within a controlled trial. Although we found no indication that remote delivery of supported selfmanagement caused harm, we would recommend future studies to explore this further.

| Implications for future research and policy
Future research should explore how telecommunication can be implemented in ways that are most valued by patients and clinicians, to fit within the organisational and technical infrastructure of healthcare services and embrace the culture of delivering supported selfmanagement. 33 Asthma UK 50 advocate that policy makers and innovators need to work together to develop a national effort towards delivering sustainable supported self-management and long-term implementation of improved patient-centred asthma care. The Asthma UK Centre for Applied Research (AUKCAR) is a collaborative network of applied asthma researchers, clinical and academic respiratory experts, as well as PhD students and asthma patient representatives. 50 Supported self-management is a key theme within the AUKCAR and the IMP 2 ART programme of work has developed evidence-based, practical strategies to promote the delivery of supported self-management in routine primary care. [51][52][53] This rapid realist review provides evidence-based findings of the underlying contexts and mechanisms in remote service provision that contribute towards effective supported self-management delivery during asthma reviews, which will be highlighted by the IMP 2 ART programme.
KINLEY ET AL.

| CONCLUSIONS
Even when the COVID-19 pandemic recedes, remote technologies will remain in everyday healthcare. This paper highlights new knowledge through the use of realist methodology by understanding the existing mechanisms and the interplay within differing contexts, and has revealed how and why remote supported self-management for asthma can be effectively delivered. A core component of asthma care is supporting self-management, a guideline-recommended intervention that reduces the risk of acute attacks, and improves asthma control and quality of life. Across a broad range of contexts, remote consultations are highly accepted by both patients and professionals, and are as clinically effective and safe as face-to-face reviews to provide self-management support. Specific groups advantaged by remote consulting included those living in rural communities, or who had to fit their healthcare around work or domestic responsibilities, and those with reduced mobility. The findings of this rapid realist review can inform the conduct of remote asthma reviews, and implementation of supported self-management techniques into asthma care.