Prof. Giorgio Walter Canonica Allergy and Respiratory Diseases Department University of Genoa
description
Transcript of Prof. Giorgio Walter Canonica Allergy and Respiratory Diseases Department University of Genoa
Grazie per aver scelto di utilizzare a scopo didattico questo materiale
delle Guidelines 2011 libra.Le ricordiamo che questo materiale è
di proprietà dell’autore e fornito come supporto didattico per uso
personale.
Prof. Giorgio Walter CanonicaAllergy and Respiratory Diseases Department
University of Genoa
Modena LIBRA, March 1st,2011
Past President 1°vice President
Unmet Needs in Unmet Needs in ASTHMA and COPDASTHMA and COPD
COPDCOPD
Calverley, B.J.P. 2008
Calverley, B.J.P. 2008
Decramer et al. Resp.Med.2011
Decramer et al. Resp.Med.2011
Decramer et al. Resp.Med.2011
Decramer et al. Resp.Med.2011
CONCLUSIONS
Morales Asenco et al. BMC 2010Morales Asenco et al. BMC 2010
PROsPatient Reported OutcomesPatient Reported Outcomes
Diseasecontrol
measures
Patientreported
outcomesTherapyDisease
phenotype
Real-life observational studies
Preference Preference
AwarenessAwareness
SatisfactionSatisfaction
BehaviourBehaviour
CopingCoping
AdherenceAdherence
StressStress
Anxiety/Anxiety/depressiondepression
Quality of lifeQuality of life
AlexithymiaAlexithymia
MoodMood
Aetiology
Severity
Comorbidities
Drugs
Schedule
Symptoms Score
Composite Score
Function
Biology
Clinical parameters
Resource utilisation
Braido et al. CMRO 2011
Braido et al. CMRO 2011
Braido et al. CMRO 2011
ASTHMAASTHMA
GUIDELINES
Asthma guidelines
Asthma Control in
Real Life
Worldwide epidemiological evaluation of asthma control level
1. Rabe et al. Eur Respir J 2000; 16: 802-8072. www.asthmainamerica.com
3. Lai et al. Eur Respir J 2003; 111: 263-268
AIRLAAsthma Insights and Reality
in Latin America
AIRLAAsthma Insights and Reality
in Latin America
7 European countries 2803 patients with asthma1
2509 patients with asthma2
8 Asian-Pacific countries 3206 patients with asthma3
11 Latin American countries 2184 patients with asthma
Achieving control in asthmatic patients: still a critical issue?
Levels of asthma control in the total sample (right), and in the subgroup of patients treated with high-dose ICS + LABA (left)
122 patients51.3% LABA + ICS
16 PTZ high-dose L + I
122 patients51.3% LABA + ICS
16 PTZ high-dose L + I
56.25 25.00
18.75
44.30
47.50
8.20
Total control Well controlled Uncontrolled
Braido et al. Allergy 2009; 64: 937-943
the total sample patients treated with high-dose ICS + LABA
Patients’ opinions on their asthma
Asthma
96 patients
Do you think your disease is under control?
Do you think you relied on qualified professionals?
How do you cope with your disease?
Have drugs improved your disease?
Are you following doctors’ prescriptions?
Do you think your disease will improve?
Do you feel helped by your family?
Do you feel helped by all the medical staff?
Not at all
–
–
3.1%
–
1.0%
19.8%
8.3%
–
A little
12.5%
7.3%
16.7%
14.6%
5.2%
33.3%
7.3%
10.4%
Fairly
58.3%
53.1%
51.0%
53.1%
50.0%
26.0%
36.5%
66.7%
A lot
22.9%
32.3%
24.0%
26.0%
39.6%
9.4%
33.3%
21.9%
Not indicated
6.3%
7.3%
5.2%
6.3%
4.2%
11.5%
14.6%
1.0%
Baiardini et al. J Investig Allergol Clin Immunol 2006; 16: 218-223
0-20% 20-40% 40-80% 80-100%2
In which percentage of patients do patient’s or asthma characteristics impose a non-compulsive treatment?Responders: 756 GPs; 214 specialists
GPs Spec GPs Spec GPs Spec GPs Spec
484
(64.02%)
137
(64.02%)
211
(27.91%)
64
(29.91%)
46
(6.08%)
10
(4.67%)
15
(1.98%)
3
(1.40%)
1.12
p=0.77
In which percentage is a model of self-management of the pathology realisable?Responders: 670 GPs; 204 specialists
436
(65.07%)
121
(59.31%)
181
(27.02%)
75
(36.77%)
31
(4.63%)
8
(3.92%)
22
(3.28%)
0
(0%)
12.76
p=0.0052
In which percentage are the results of clinical trials confirmed in real life?Responders: 727 GPs; 205 specialists
179
(24.62%)
43
(20.98%)
311
(42.78%)
92
(44.88%)
158
(21.73%)
53
(25.85%)
79
(10.87%)
17
(8.29%)
3.28
p=0.35
In which percentage are guideline indications applicable in real life?Responders: 720 GPs; 207 specialists
107
(14.86%)
27
(13.04%)
287
(39.86%)
62
(29.95%)
178
(24.72%)
65
(31.40%)
148
(20.56%)
53
(25.60%)
9.19
p=0.0269
Braido et al. J Investig Allergol Clin Immunol 2010; 20: 9-12
Real-life asthma management
Baiardini et al. Curr Opin Allergy Clin Immunol 2009; 9: 228-233
LACK of:
•Consciousness
•Familiarity
•Agreement
•Auto- effectiveness
•Success expectation
•Motivation and consolidation
External barriers
Why do doctorsdoctors not follow guidelines?
Baiardini et al. Curr Opin Allergy Clin Immunol 2009; 9: 228-233
Why do patientspatients not follow guidelines?
Baiardini et al. Curr Opin Allergy Clin Immunol 2009; 9: 228-233
Adherence to treatmentAdherence to treatmentis a weak pointis a weak point
in asthma managementin asthma management
World Health Organisation20032003
World Health Organisation
Cutler and Everett. NEJM 2010; 362: 1553-1555
Cutler and Everett. NEJM 2010; 362: 1553-1555
Cutler and Everett. NEJM 2010; 362: 1553-1555
COPDCOPD
Breekveldt-Postma et al. Pharmacoepidemiol Drug Saf 2008; 17: 411-422
1.0
0.8
0.6
0.4
0.2
0.0
Prop
ortio
n of
per
sist
ent I
CS u
sers
by
form
ulati
on in
adu
lts
400350300250200150100500
Time since start of therapy (days)
1.0
0.8
0.6
0.4
0.2
0.0
Prop
ortio
n of
per
sist
ent I
CS u
sers
by
form
ulati
on in
chi
ldre
n an
d ad
oles
cent
s
400350300250200150100500
Time since start of therapy (days)
Fixed Single
Adults Children and adolescents
Overall persistence with single andOverall persistence with single and fixed ICS treatment in new users with asthma fixed ICS treatment in new users with asthma
Unmet needs in asthma: Global Asthma Physician and Patient (GAPP Survey):
global adult findings
Canonica et al. Allergy 2007; 62: 668-674
Patients and physicians disagree on content of education provided and received
11
22
42
53
69
30
44
73
78
95
0 20 40 60 80 100
Physicians
PatientsContact patient support organisation
Keep daily symptom/medication diaries
Monitor peak expiratory flow
Develop individual management plan
Correct inhaler technique
Respondents (%)
Does your doctor or other healthcare professional in his or her office discuss any of the following with you? Base: all respondents (patients)Do you regularly discuss the following with your asthma patients? Base: all respondents (physicians)
Patients perceive that only 25% of office visit time is devoted to asthma education
Patients perceive that only 25% of office visit time is devoted to asthma education
Canonica et al. Allergy 2007; 62: 668-674
Treatment compliance increases with increased patient education
<51%
15%
51-80%
27%
81-99%
29%
100%
30%
Patient treatment compliance
Amount of time spent on patient education
Increase in compliance (%)
Canonica et al. Allergy 2007; 62: 668-674
Time with doctor in primary careMalaysia 5-10 minsPakistan <3 minsUK 8 minsAustralia 15 minsSouth Africa 8-11 minsItaly 8 mins
E BatemanE Bateman
This should be avoided!!!This should be avoided!!!
Horne et al. BMC Pulm Med 2007; 7: 8
Can asthma control be improved by understanding the patient’s perspective?
Patient
Asthma: physician’s and patient’s viewpoint – two different perspectives
Physician
Asthma
InflammationComorbidityIgEAtopyHistamineBronchoconstrictionFEV1
Asthma
SleepEatingPhysical functioningSocial lifeSportWork PerformanceMental functioningSchool Performance
Patient
A general process in guidelines evolution
Evidence-based
medicine
Evidence-based
medicine
Factors that influence the strength of a recommendation
• Balance between desirable and undesirable effects
• Quality of evidence
• Patients’ values and Patients’ values and preferencespreferences
• Costs
PROs to support medical product labelling claims:FDA perspective
PROs provide a unique perspective on medical therapy, because some effects of a health condition and its therapy are known
only to patients
PROs provide a unique perspective on medical therapy, because some effects of a health condition and its therapy are known
only to patients
Patrick et al. Value Health 2007; 10 (Suppl 2): S125-S137FDA, Food and Drug Administration
Braido et al. Allergy 2010: DOI: 10.1111/j.1398-9995.2010.02383.x.
Baiardini et al. J.ASTHMA 2011
Baiardini et al. J.ASTHMA 2011
Physician’s and patient’s viewpoint
Physician Patient
Limits Emotions
KnowledgeSatisfaction
FearSleep
SchoolRelationships
DiagnosisDrugsFollow-upGuidelinesSeverityComorbidityCostsClinical parametersFunctional parameters
Education
Consideration
Disease management
Characterisation of chronic diseases• Persistance, more years of disability and handicap,
shorter life expectancy and can totally or partly be abrogated by a continuous action by healthcare professionals
World Health Organisation
Physical functioning
Life expectancy
Chronic disease management
Disease Management is crucial
PROs should be priority outcomes of treatments
Adherence to treatment is our ultimate goal
Take home messages
Knowledge and health care resources allocation in asthma management: impact of one-year guidelines based CME/CPD course
Braido F*, Comaschi M°, Valle I§, Delgado L+, Coccini A§,
Guerrera P°°, Stagi E**, Canonica GW* on behalf of ARGA Study Group and EAACI/CME Committee f.
Braido F* et al. submitted
Braido F* et al. submitted
• Material and methods
• Study design
• The educational program was made up
of 5 residential events with 4 short distance of 5 residential events with 4 short distance learning courses in-betweenlearning courses in-between.
• The scientific contents of the courses were based on the economical analysis of Anatomical Therapeutic Chemical Classification System (ATC) Respiratory (R) drugs prescription and healthcare resource usage data related to the previous three-months, blindly obtained from the database of Local Health Unit ASL No 3 of Genoa.
Braido F* et al. submitted
Single Drug Prescriptions
Braido F* et al. submitted
Results • Fourteen GPs (46.7%) completed the training
course and 6 (20%) completed the distance-the distance-learning part.learning part.
• Knowledge improved Knowledge improved significantly after training (p <0.001, correct answers to key questions +13%).
• Training resulted in pharmaceutical cost containment (trained GPs +0.5% vs controls +18.8%) and greater attention to diagnosis and monitoring (increase in spirometry +63.4% , p 0.01).
Braido F* et al. submitted
Final Take Home Message
GUIDELINES ARE INTERVENTIONALLY EFFECTIVEWHENEVER PROPERLY IMPLEMENTED