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The ARGA study with general practitioners: Impact of medical education on asthma/rhinitis management
Abstract
To evaluate the impact of a medical education course (MEC) on the behaviour of general practitioners (GPs) to treat asthma and allergic rhinitis (AR).
Data on 1820 patients (mean age 41 yrs ± 17 yrs) with asthma or AR were collected by 107 Italian GPs: 50% attended a MEC and 50% didn't (group B). The adherence for AR and asthma treatment was evaluated according to ARIA and GINA guidelines (GL).
AR and asthma were diagnosed in 78% and 56% of patients; 34% had concomitant AR and asthma. Regardless of the MEC, the adherence to GL was significantly higher for AR than for asthma treatment (52 versus 19%). Group B GPs were more compliant to ARIA guidelines in the treatment of mild AR, whereas group A were more compliant in the treatment of moderate-severe AR; the adherence didn't differ between the groups for AR patients with comorbid asthma. Adherence to GINA GL for asthma treatment did not differ between GPs of groups A and B, independently from concomitant AR. Though insignificantly, group A were more compliant to GINA GL in the treatment of patients with only severe persistent asthma (63 versus 46%) as group B were for patients with severe persistent asthma and concomitant AR.
GPs often tend to treat patients independently from GL. The impact of a single MEC did not improve adherence to GL in treating less severe AR and asthma patients, while there was a trend towards the opposite attitude in more severe AR patients without concomitant asthma.
... To achieve this goal, guidelines were published with indications about medication use, control of the environment and health education. Unfortunately, evidence exists that guidelines recommendations are often not applied within the clinical practice [4]. Therefore, asthma control, as recommended by guidelines, has been shown to be satisfactory in less than 30% of children [1]. ...
... The most recent GINA guidelines underline the physician's role in asthma management and care, emphasizing that a proper control of the disease depends on doctor's ability and experience in recognizing symptoms (considering possible differential diagnoses), defining the severity level (also by evaluating the respiratory function, as recommended by international guidelines), prescribing the correct medication and educating the patient and his family [6]. Recent data demonstrate that physicians often ignore guidelines [4] and the importance of using asthma control tools [1]. ...
... Unexpectedly, in the sample of children without a doctor diagnosis of asthma, there was someone who took medications (bronchodilators or inhaled corticosteroids) to improve its respiratory symptoms. These observations may suggest both a poor adherence of physicians to guidelines within clinical practice [4], and a non-adherence of patients to the treatment plan. Previous studies reported that even patients with severe asthma do not follow the treatment properly. ...
... To achieve this goal, guidelines were published with indications about medication use, control of the environment and health education. Unfortunately, evidence exists that guidelines recommendations are often not applied within the clinical practice [4]. Therefore, asthma control, as recommended by guidelines, has been shown to be satisfactory in less than 30% of children [1]. ...
... The most recent GINA guidelines underline the physician's role in asthma management and care, emphasizing that a proper control of the disease depends on doctor's ability and experience in recognizing symptoms (considering possible differential diagnoses), defining the severity level (also by evaluating the respiratory function, as recommended by international guidelines), prescribing the correct medication and educating the patient and his family [6]. Recent data demonstrate that physicians often ignore guidelines [4] and the importance of using asthma control tools [1]. ...
... Unexpectedly, in the sample of children without a doctor diagnosis of asthma, there was someone who took medications (bronchodilators or inhaled corticosteroids) to improve its respiratory symptoms. These observations may suggest both a poor adherence of physicians to guidelines within clinical practice [4], and a non-adherence of patients to the treatment plan. Previous studies reported that even patients with severe asthma do not follow the treatment properly. ...
... Taking into consideration the continuously increasing prevalence of allergic disorders in many parts of the world, as well as the dramatic challenges from environmental factors due to climate changes, the importance of respiratory allergies has to be considered from many public and individual perspectives [34]. Since the spectrum of allergy services is very heterogeneous across Europe, the role of GPs and other specialists has to be better defined and based on adequate training [35]. ...
Background: Respiratory allergies mostly allergic rhinitis and asthma represent an important and increasing public health problem and one of the priorities for the European health systems. There is an increasing public concern regarding the persistence and severity of allergic diseases and many difficulties of health systems in providing prompt specialized medical assistance. Our study aims to highlight the main results of the Alliance 4Life project focused on the evaluation of the burden and management of respiratory allergies in primary care from Romania and comparative health-related data from four Central and Eastern European countries.
Method: We developed a questionnaire focused on patients with allergic rhinitis and asthma directly addressed to general practitioner (GP) specialists from Romania who attended the annual national conference in Bucharest.
Results: The main results showed that patients with respiratory allergies are frequently encountered in primary care practice, only a few patients are evaluated by allergists and there is a clear need for education in this field.
Conclusions: This preliminary study confirms that respiratory allergies represent a considerable burden in primary care and the questionnaire may be a useful tool in further studies considering the experience of other healthcare systems. More advanced studies integrating epidemiology with data on air pollution and environmental conditions should be envisaged.
... [12] Despite the wide availability of alternative treatments mentioned in the ARIA guidelines, many primary care physicians show poor adherence to these guidelines and continue to treat the disease incompletely. [1,13] Adherence to ARIA guidelines has been associated with better patient outcomes. [14] In comparison to other parts of the world, statistics on primary care attitudes and practices toward the management of AR in Saudi Arabia are still limited. ...
A BSTRACT
Background
Allergic rhinitis (AR) is considered one of the most common reasons for patients visiting primary health care clinics. Physicians’ adherence to management guidelines for AR results in better patient outcomes. Therefore, the present study aimed to assess the knowledge, attitudes, and practices of primary health care practitioners (PHCPs) towards allergic rhinitis guidelines in Saudi Arabia.
Methods
This observational cross-sectional study conducted from August 2021 to November 2021 included 282 primary care physicians across all regions of Saudi Arabia. We used a two-part, validated, self-administered Perception Attitude and Practice of Primary Care Practitioners questionnaire. The first part was demographics, and the second part comprised three domains (perception, attitude, and practice) including 48 items. Statistical Package for the Social Sciences (SPSS), version 21 was used to analyze the data.
Results
Most of the 282 physicians were Saudis (79%). Allergic rhinitis and its impact on asthma (ARIA) guidelines were recognized by 71% of the physicians. Second-generation oral antihistamines were considered the safest drug by the majority (82%), followed by intranasal corticosteroids (75.2%). Most physicians diagnosed AR based on clinical history (95%), while (43%) utilized allergy testing. Intranasal corticosteroids were the most preferred treatment option (70%) followed by second-generation and first-generation oral antihistamines (66% and 55%, respectively).
Conclusion
Our study demonstrates the importance of education and awareness for PHCPs managing AR. ARIA guidelines should be implemented as a standard of care for AR, as PHCPs are the first ones to encounter patients with AR, to improve outcomes and avoid undertreatment and complications.
... The infection caused by EV is known as enterobiasis or oxyuriasis, and affects about 200 million people around the world, mainly children, with a symptomatology characterized by anal itching and intestinal disorders. However, the involvement of the gastrointestinal tract can be severe and cause death [1][2][3][4][5][6][7][8][9]. The mortality rate due to EV is not significant, but infections caused by intestinal worms can be a significant public health and economic concern in countries where these infections remain endemic. ...
Background: Enterobiasis or oxyuriasis from Enterobius vermicularis is an infection
usually localized in the large bowel and cecum. Generally, the symptoms are characterized by anal
itching, and intestinal or nervous disorders. Rarely, it is responsible for death. Methods: A forensic
autopsy of a 52-year-old white male inmate who died 5 days after hospitalization was performed.
Histological and toxicological analyses were also performed. Results: The death occurred by
localization of Enterobius vermicularis in the duodenum and in the proximal ileum, with intestinal
haemorrhage, inflammation, and peritonitis documented by histological examination. Conclusion:
This is a common infectious disease, and can rarely occur with a fatal outcome, even in advanced
populations. The lack of knowledge related to the rarity of death from enterobiasis disease can
determine a dangerous concern.
... It is common for patients to seek medical advice from primary care for their allergic conditions. Although primary care physicians are expected to manage allergic diseases appropriately, several studies in the literature showed an inadequate knowledge level with some degree of incompetency in rationally implementing the pharmacotherapy based on relevant guidelines (2)(3)(4). ...
Objective: Allergic diseases are conditions that are frequently encountered in primary care, and different drug groups can be used in their treatment. This study aimed to compare the use of drugs in allergy in children and adults applied to primary care. Methods: We analyzed prescriptions written by those who were selected by systematic sampling (n=1431) among family physicians serving in İstanbul between January 1 and December 31, 2016. Among these, single-diagnosis prescriptions containing “T78.4-allergy, unspecified” were included in the study, and the prescriptions were divided into those written to children (<18 years old) and adults (≥18 years old). The demographic characteristics of the patients and drug details in the prescriptions were compared according to the groups.
Results: A total of 37,042 prescriptions with a single diagnosis of allergy were identified, and 55.9% of which were for adults. Allergy diagnosis was higher in men (52.4%) among children and in females (67.7%) among adults. Antihistamines (85.3% and 83.4%, p<0.001), systemic steroids (5.4% and 1.6%, p<0.001), and inhalants (1.8% and 1.3%; p<0.001) were more likely prescribed to adults, whereas topical drugs were prescribed more in children (51.7% and 42.7%, p<0.01). Monotherapy was more preferred in children (45.8%) than in adults (41.6%, p<0.0001). Although antihistamine monotherapy was similar in these groups, topical drug monotherapy was used more in children (10.3%) than in adults (5.6%). Prescriptions with first-generation antihistamines were higher in adults (6.8%) than in children (5.4%; p<0.001). Desloratadine was the most commonly encountered drug in the prescriptions of both pediatric and adult patients (21.2% and 10.3%, respectively).
Conclusion: The study revealed that antihistamines, mostly second-generation agents, are frequently preferred. Apart from the higher prescription of systemic corticosteroids for adults and topical drugs for children, it is understood that the pharmacological management of allergic conditions in primary care shows overall similarities in both age groups.
... Its results revealed 107 cases of undiagnosed asthma suggesting that 65% of paediatric asthma cases were undiagnosed (4). Such a finding may reflect a number of factors including socioeconomic factors, restricted access to specialized diagnostic facilities, so called labelling effect or vary-ing diagnostic criteria between consulting physicians (1,(5)(6)(7). On the other hand, underdiagnosis of paediatric asthma may be related to the intricacies of a natural history of the disease. ...
Objectives:
Our recent studies showed that in children in the Batumi region, Georgia, underdiagnosis of asthma is 65%, and that not all children with known asthma had a history of allergic disorders. So, we decided to assess the association of known diagnosis of paediatric asthma with asthma-like symptoms and non-respiratory allergic symptoms and diseases using questionnaire-derived data provided by respiratory health survey.
Methods:
Subjects of the cross-sectional population-based study were 3,239 urban and 2,113 rural children aged 5-17 years whose respiratory status was assessed using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. For children with a known diagnosis of asthma, the occurrence of respiratory symptoms suggestive of asthmatic tendency and of allergic symptoms and diseases was measured and statistical association of known asthma with the respiratory and allergic symptoms was expressed as odds ratios (OR) and their 95% confidence intervals (95% CI).
Results:
Respiratory and all allergic symptoms and diseases, except for eczema, were statistically significantly (p < 0.05) more prevalent in children with asthma than in children without asthma. Based on the distribution of asthma vis-à-vis asthmatic tendency without or with allergic symptoms and allergic diseases the following odds ratios expressing likelihood of asthma were obtained: for asthmatic tendency: OR = 18.09 (95% CI: 11.82-27.68), for any allergic symptom: OR = 6.85 (95% CI: 4.69-10.02), for any allergic disease: OR = 10.75 (95% CI: 7.36-15.70), for asthmatic tendency with coexisting any allergic symptom: OR = 18.94 (95% CI: 12.96-27.68), for asthmatic tendency with coexisting any allergic disease: OR = 25.65 (95% CI: 17.47-37.67), and for asthmatic tendency with coexisting any allergic symptom and allergic disease: OR = 27.02 (95% CI: 18.18-40.15).
Conclusions:
The findings support the view that in epidemiological setting questionnaire-based studies on asthma seems to more readily identify cases in children with more severe clinical presentation of the disease and with coexisting allergic disorders, perhaps reflecting diagnostic practices of consulting paediatricians.
... A study among Italian general practitioners showed that they treat patients independently of guidelines. 8 In Canada, unprompted awareness of ARIA guidelines was nonexistent among primary care practice (0%). 1 This is partly due to the use of local guidelines in their practices instead of ARIA. Nonetheless, there is very limited information available on the reasons why the ARIA guidelines have not been properly utilized despite being widely accessible. ...
Background
Primary care practitioners (PCPs), being the front liners, play an important role in treating allergic rhinitis (AR). As there is no proper tool to assess their perception, attitude, and practice in utilizing the guidelines, we aimed to develop and validate a new questionnaire for such purpose.
Methods
The development phase consists of both literature and expert panel review. The validation phase consists of content validity, face validity, and construct validity. Cronbach's alpha was used to verify internal consistency. The development phase produced a questionnaire with 3 domains: perception, attitude, and practice consisting of 60 items (PAP-PCP questionnaire). Item response theory analysis for perception demonstrated the difficulty and discrimination values were acceptable except for 3 items. Exploratory factor analysis for attitude and practice domains showed the psychometric properties were good except for 3 items in practice domain. Experts judgement was used to decide on the final selection of questionnaire which consists of 59 items.
Results
The final validated questionnaire has 3 domains with 59 items. All domains had Cronbach's alpha above 0.65 which was reliable. 302 physicians completed the questionnaire. 98% PCPs diagnosed AR based on clinical history. Although, majority agree AR guidelines is useful (67%), they had difficulty in using it to classify AR (54.9%) and determine AR severity (73.9%). Oral anti-histamines (first and second generation) were the most prescribed (>75%) followed by intranasal corticosteroids (59%) and combined intranasal corticosteroid and oral anti-histamine (51%). Majority agreed that treatment efficacy (81.8%), adverse effects (83.8%), fear of adverse effects (73.5%), route of administration (69.4%), dosing frequency (72.5%), taste (64.6%) and cost (73.5%) affect treatment compliance.
Conclusions
The newly developed and validated questionnaire is a promising instrument in understanding the treatment gap in AR. Although further testing and refinement are needed, it provides an initial means for evaluating knowledge and understanding of PCPs in treating AR.
... An inappropriate secretion of adipokines seems to participate in the pathogenesis of obesity-related diseases including endothelial dysfunction, inflammation and atherosclerosis 45 . In particular, the intercorrelation between adipose tissue and lung has become clear; the involvement of leptin and adiponectin has been demonstrated in several lung diseases such as COPD, emphysema, asthma and cancer [46][47][48][49] . In fact, through the secretion of adipokines, adipose tissue participates in the regulation of several patho-physiological processes in many organs and tissues. ...
Chronic obstructive pulmonary disease (COPD) represents a complex respiratory disorder characterized by persistent respiratory symptoms due to chronic airflow limitation caused by exposure to noxious particles/gases with an increased inflammatory response of the airways. COPD is common in older people, with an estimated prevalence of 10% in the US population aged > 75 years and is often accompanied by other concomitant chronic conditions that negatively impact prognosis and health status. The aim of this paper is to highlight the relationship between COPD and other comorbidities in elderly population. We focus our attention on the relationship existing between COPD and cardiovascular diseases, lung cancer, obstructive sleep apnoea syndrome, malnutrition/sarcopenia and osteoporosis with particular attention to adipokines, considering that adipose tissue plays a relevant role in the cross-talk between organs.
... Best practice mandates that both physicians and patients should be involved in the decision-making process of initiating and maintaining appropriate treatment for AR. According to recent European surveys, the awareness of and adherence to ARIA guidelines varies significantly between Otorhinolaryngology specialists and General Practitioners (GPs) 14,15 . Currently, there exists wide heterogeneity in patient expectation, preference and satisfaction with AR treatment internationally 16,17,18 . ...
Nasal corticosteroid sprays are the recommended, first-line treatment in the management of allergic rhinitis. Patient compliance and spray technique appear to be significant issues. There is a paucity of information in medical literature, regarding patient knowledge, perception, and satisfaction of the use of nasal corticosteroid sprays. A prospective, questionnaire-based study was performed, Patient knowledge, perception, and technique of using nasal corticosteroid sprays was assessed. One hundred patients completed the questionnaire. Ages ranged from 16 to 68 years. 89%(n=89) had no knowledge of the required duration of treatment. 60%(n=60) were not shown how to administer the spray. 55%(n=55) did not know their spray contained steroids. 39%(n=39) gave up their treatment in under two weeks, primarily because they reported minimal or no improvement in nasal symptoms. 80%(n=80) of patients had poor spray technique. All patients complained of one or more side effects. Patients administering corticosteroid intranasal sprays possess limited knowledge and awareness of the treatment for allergic rhinitis. They do not receive sufficient instruction regarding administering the spray or duration of use, and subsequently achieve suboptimal satisfaction with their management. A knowledge gap exists that could be bridged by better patient education.
... 11 In pediatric practice such a possibility cannot be neglected in light of the fact that current diagnostic guidelines are often not applied by general practitioners. 12 We do not have data regarding insufficient application of pertinent diagnostic standards by pediatricians in Batumi but in our opinion it represents a real problem in primary health units. ...
Background and objective:
A recent survey in Batumi, Georgia showed a low prevalence of asthma in children (1.8%). A potential explanation is underdiagnosis of asthma. To investigate this, we conducted a follow up to the survey with the objective of estimating the level of childhood asthma underdiagnosis and to describe factors related to it.
Methods:
Subjects included 437 survey participants who had a history of asthma-like symptoms and no diagnosis of asthma. All children underwent clinical examination (spirometry, skin prick tests, FeNO measurement) to identify new cases of asthma. The distribution of host and environmental factors was compared between the group with newly identified asthma and a group of 59 children with previously known asthma (diagnosed asthma).
Results:
Clinical investigation identified 107 cases of undiagnosed asthma. The corrected asthma prevalence estimate was 5.1% (95%CI: 4.4%-5.9%) suggesting that 65% of asthma cases were undiagnosed. Compared to children with diagnosed asthma, children with undiagnosed asthma were younger (8.2±1.6 vs. 9.3±2.1; p=0.0005), had less frequent history of allergic disorders (38.3% vs. 64.4%; p=0.001), and a lower prevalence of parental asthma (1.8% vs. 8.4%; p=0.04). The groups did not differ in terms of environmental characteristics except for more exposure to passive smoking in the undiagnosed asthma group (p=0.01). Multivariate analysis confirmed results of simple analyses.
Conclusion:
In Batumi, 65% of children with asthma remain undiagnosed. Older age of a child, coexisting allergic disorders, and parental asthma seem to facilitate diagnosis. Implementation of current diagnostic guidelines should improve diagnostic accuracy of pediatric asthma in Batumi.
... Some studies have reported an association between increased levels of inflammation biomarkers such as TNF-α, malnutrition status, and poor outcome in patients with HF [35][36][37]. Mechanistically, the activation of neurohormonal and inflammatory pathways that characterize cardiovascular disease may increase the catabolic demand, and patients with already poor nutritional status may be more vulnerable to cardiac events. Moreover, the protective and beneficial role of physical activity on ischemic cardiac disease is well recognized [38]. ...
Background: Malnutrition is a frequent condition in the elderly, and is associated with prolonged hospitalization and increased mortality. However, the impacts of malnutrition among elderly patients with acute myocardial infarction have not been clarified yet. Methods and Results: We enrolled 174 patients aged 65 years and over, admitted with the diagnosis of acute myocardial infarction (AMI), who underwent evaluation of nutritional status by Mini Nutritional Assessment (MNA) and evaluation of mortality risk by GRACE Score 2.0. All-cause mortality was the outcome considered for this study. Over a mean follow-up of 24.5 ± 18.2 months, 43 deaths have been registered (24.3%). Non-survivors were more likely to be older, with worse glomerular filtration rate, lower systolic blood pressure, lower albumin and MNA score, higher prevalence of Killip classification III-IV grade, and higher Troponin I levels. Multivariate Cox proportional analysis revealed that GRACE Score and MNA showed a significant and independent impact on mortality, (HR = 1.76, 95%, CI = 1.34–2.32, and HR = 0.56, 95% CI = 0.42–0.73, respectively). Moreover, the clinical decision curve revealed a higher clinical net benefit when the MNA was included, compared to the partial models without MNA. Conclusion: Nutritional status is an independent predictor of long-term mortality among elderly patients with AMI. MNA score in elderly patients with AMI may help prognostic stratification and identification of patients with, or at risk of, malnutrition in order to apply interventions to improve nutritional status, and maybe survival in this population.
... General practitioners often tend to treat patients independently from international guidelines (GINA). The impact of a single medical educational course did not improve adherence to guidelines in treating less severe allergic AR and asthma patients, while there was a trend toward the opposite attitude in more severe allergic AR patients without concomitant asthma [82] . ...
Introduction: Asthma and allergic rhinitis (AR) are chronic conditions in which management needs adherence to prescribed drugs. Despite the benefits of regular maintenance of asthma and AR therapy, low adherence is a frequent issue in clinical practice.
Areas covered: The aim of this review is to provide a targeted analysis of the more recent literature on adherence in asthma and AR, focused on the following areas: adherence extent, barriers and consequences, effects of educational interventions and use of new technologies to improve the level of adherence.
Expert commentary: Despite the extent, reasons and effects of this problem being well known, non-adherence in asthma and allergic AR remains worryingly high. Poor adherence leads to unsatisfactory health outcomes, with a negative impact on patients and society. Recent literature suggests that successful programs to improve adherence should include a combination of strategies. The new technologies represent a promising tool to improve adherence.
... outpatient or hospitalized 5 ) and on the diagnostic criteria applied 4 . The coexistence of the two conditions is further supported by shared risk factors, notably age and smoking 4 6 7 . ...
Chronic Obstructive Pulmonary Disease (COPD) and Heart Failure (HF) are major and increasing public health problems worldwide. Both conditions are common diseases of the elderly and often coexist. Unfortunately their coexistence frequently remains unrecognized mainly due to the similarities in clinical presentation and additionally due to a lack of relevant studies addressing the combination of HF and COPD. The coexistence of HF and COPD presents many diagnostic challenges. Several tests can be performed to assist in the diagnosis of each disease. Assessment of left ventricular function by transthoracic echocardiography is mandatory for diagnosing HF, while magnetic resonance imaging is the modality of choice in those with limited acoustic windows. On the other hand, objective evidence of airflow obstruction, demonstrated when clinically euvolemic is mandatory for diagnosing COPD. Greater collaboration is required between cardiologists, pulmonologists, and general practitioners. Both are chronic progressive diseases and their prognosis combined is poorer than for either disease alone, therefore it is really important to recognize the coexistence of both processes early.
... These problems have clinical and public health implications. Current diagnostic guidelines are often not applied [15]. Moreover, children with less respiratory symptoms, with less severe presentation or without the usual allergic co-morbidities, are more likely to be undiagnosed [16,17]. ...
Introduction
The presented study of 4,535 children aged 7–17 years in the Upper Silesian region of Poland yielded 186 cases of previously known asthma, and 44 children with newly diagnosed asthma. The aim of the presented study was to identify non-medical factors that could explain why children with a newly established diagnosis (‘undiagnosed asthma’) had not been diagnosed in the past.
Material and Methods
The study was performed according to a case-control design. Parents of the children answered questionnaires on socio-economic status and family-related factors. Statistical determinants of undiagnosed asthma were explored using raw (OR) and logistic odds ratios with their 95% confidence intervals (logOR, 95%CI).
Results
Children with undiagnosed asthma were younger compared to the group with previously known asthma (11.3±2.1 vs. 12.6±2.5 years; p=0.0008). Newly diagnosed cases were more frequent in children who had less parental attention (less than 1 hour/day spent by parent with child – OR=4.36; 95%CI: 1.76–10.81) and who were not registered with specialized health care (OR=2.20; 95%CI: 0.95–5.06). Results of logistic regression analysis suggest that under-diagnosis of asthma is related to age below 12 years – logOR = 3.59 (95%CI: 1.28–10.36), distance to a health centre > 5 km – logOR = 3.45 (95%CI: 1.05–11.36), time spent with child < 1 hour/day – logOR = 6.28 (95%CI: 1.98–19.91).
Conclusions
Among non-medical determinants of undiagnosed asthma the age of a child plays a major role. Another factors of importance is the large distance between residence and health centre, and low parental attention at home.
... 7 Having information on which group of patients needs more attention in terms of education, follow-up, and adherence to the therapy could help tailoring practical interventions by general practitioners and specialists toward a better control of allergic rhinitis symptoms. The aim of this study is to elucidate predictors of allergic rhinitis under-/ no treatment in participants recruited by their general practitioners, as a part of the ARGA study, [10][11][12] focusing mainly on patients characteristics, type of symptoms, and on the relationship between allergic rhinitis and asthma. ...
Although allergic rhinitis is considered a raising medical problem in many countries it is often undertreated. The reasons for this phenomenon are not completely clear.
The aim of this study is to evaluate factors associated with allergic rhinitis under-/no treatment.
A sample of 518 allergic rhinitis patients recruited by their primary care physicians, as a part of the ARGA study, were invited to fill in a specific questionnaire regarding rhinitis symptoms, treatment, and rhinitis-related work/social disability. Chi-square test and logistic regression were performed to assess risk factors for allergic rhinitis under-/no treatment.
Over one out of four patients had no treatment despite the symptoms and 13.5% were inadequately treated. Participants with asthma (OR 0.47, 95% CI 0.30–0.75) and conjunctivitis (0.44, 95% CI 0.27–0.71) were at lower risk of allergic rhinitis under-/no treatment: in asthmatics this reduction was related mainly to the concomitant asthma treatment (OR 0.19, 95% CI 0.10–0.37).
Asthmatics with under-/not treated rhinitis had the highest prevalence of rhinitis-related quality of life impairment.
Under-/no treatment for allergic rhinitis is still rather frequent despite the relevance of this disease. The simultaneous presence of asthma and an anti-asthmatic therapy are able to influence positively the treatment. Targeted interventions toward a better characterization and a tight follow-up of rhinitis patient without asthma are needed.
... Of those who are aware of the guidelines, 62% report that they always or mostly follow the ARIA algorithm in their daily management [6]. A study of Italian general practitioners (GPs) shows that they treat patients independently of guidelines [7]. In Southeast Asia, a survey of Malaysian ENT (ear, nose, throat) specialists and GPs shows that their management of mild and moderate to severe AR is consistent with ARIA guidelines [8]. ...
Background:
Treatment of allergic rhinitis (AR) consistent with consensus guidelines is reported to result in better patient outcomes. However, physicians may manage patients independently of guidelines. Asian data on physician perspectives regarding AR diagnosis and management is limited.
Objective:
The study objective is to assess attitudes and practices on AR of Filipino specialists and generalists.
Methods:
A cross sectional survey of 100 specialists and 100 generalists was conducted from November 2014 to January 2015. A previously validated and pilot tested questionnaire was administered via structured face to face interviews.
Results:
Specialists reported greater adequate knowledge of AR (specialists, 58%; generalists, 39%) and adherence to guidelines (specialists, 84%; generalists, 54%). Diagnostic tests were not routinely used (specialists, 81%; generalists, 92%). Monotherapy, specifically antihistamines, was preferred for mild AR. For moderate-severe AR, preference for monotherapy versus combination therapy (specialists, 49% vs. 51%; generalists, 44% vs. 56%) was similar. Both groups preferred intranasal corticosteroid spray (INCS) for monotherapy and antileukotrienes, antihistamines, INCS for combination therapy. For adjuvant therapy, specialists (82%) preferred nasal irrigation/douche. Primary consideration for choice of therapy was efficacy. Cost was the perceived reason for patients' noncompliance with treatment.
Conclusion:
Despite differences in awareness of and adherence to guidelines, prescribing patterns on management of mild and moderate-severe AR are similar among Filipino specialists and generalists. This can be attributed to a shared perception of efficacy and cost as drivers for therapeutic choices.
... In the last decades the worldwide population has exhibited an increasing life expectancy with a consequent raise in elderlies, with resultant impact on the prevalence of age-related diseases, with the cardiovascular conditions as the most prevalent illnesses 1 . Increasing evidence suggests that chronic systemic inflammation and accumulating oxidative stress are related to the aging process and play a role in developing many chronic diseases such as atherosclerosis, hypertension, COPD [2][3][4][5][6][7][8] . At the same time metabolic changes show high influence in to prevent or to reduce the severity of age-related pathologies, suggesting that management of these factors could have an effect on the progression of the diseases [9][10][11] . ...
Oxidative stress is implicated in the pathophysiology of several cardiovascular diseases, as evidenced by correlation between oxidative stress markers and Heart Failure (HF) and by direct molecular evidence for an etiological role of reactive oxygen species (ROS). ROS play an important role in signalling processes, but their overproduction generates oxidative stress. Previous studies demonstrated that HF was associated with antioxidant deficit as well as increased oxidative stress. Furthermore, these changes correlated with the hemodynamic function, suggesting their role in the pathogenesis of cardiac dysfunction. An important mechanism involved in cellular cardiovascular response is represented by sirtuins. SIRT1 inhibition determines suppression of genes ac tivated by exposure to heat shock, on the contrary, SIRT1 activation enhances the heat shock response. Then the ability of SIRT1 to modulate stress resistance is multifaceted and not only linked to oxidative stress, but also to other stressful stimuli. Recently several studies have demonstrated the capability of physical activity to induce SIRT1 activity and, in turn, the ability of this enzyme to mediate the favourable antioxidant effects of the exercise training. Other agents able to induce SIRT1 activity have demonstrated some effects on cardiac function. Resveratrol supplementation has been shown to decrease cardiovascular risk factors, and the positive effect of resveratrol on training response and aerobic capacity in rats to be mediated via SIRT1. The future research should be addressed to better clarify the possible role of the antioxidants therapy in clinical studies, in particular defining a standardization of procedures, doses and duration of treatment.
... Existing therapies are essentially symptomatic and not able to positively influence the course of the disease [4][5][6]. Moreover, the guidelines for respiratory disorders, including COPD, are not well clear and thus often disappointing [7,8]. ...
Chronic Obstructive Pulmonary disease (COPD) is an inflammatory syndrome that represents an increasing health problem, especially in the elderly population. Drug therapies are symptomatic and inadequate to contrast disease progression and mortality. Thus, there is an urgent need to clarify the molecular mechanisms responsible for this condition in order to identify new biomarkers and therapeutic targets. Processes including oxidant/antioxidant, protease/antiprotease, and proliferative/antiproliferative balance and control of inflammatory response become dysfunctional during aging as well as in COPD. Recently it was suggested that Sirtuin 1 (SIRT1), an antiaging molecule involved in the response to oxidative stress and chronic inflammation, is implicated in both development and progression of COPD. The present review focuses on the involvement of SIRT1 in the regulation of redox state, inflammation, and premature senescence, all crucial characteristics of COPD phenotypes. Recent evidence corroborating the statement of the "aging theory for COPD" was also discussed.
... A large retrospective study performed in the U.S. reported that less than 40% of patients prescribed ICS/LABA treatment required such a combination treatment; with the appropriate treatment being more likely prescribed by pulmonologists [4]. Similarly an Italian prospective study found that up to 30% of patients with intermittent or mild persistent asthma were prescribed ICS/LABA in primary care [2]. The most common reason is likely related to the fact that newly diagnosed asthma patients frequently receive ICS/LABA combination as first treatment at the time when they are symptomatic and require rapid and effective treatment. ...
... Updated training of family doctors in drug allergies is very important for improving the management and for reducing hospital burden and costs related to these diseases. Coordinated and sustained educational national programmes are needed, based on currently accepted international scientific and clinical standards in allergic diseases [5,6]. ...
Recent data from literature have shown many difficulties in managing allergic diseases in primary care in most countries and a consequently clear need for standardized educational programmes .Drug allergies represent an important medical issue for general practitioners (GPs) in Romania, though no national data about incidence, severity and management exist.The aim of our study was to evaluate epidemiological aspects of drug allergies in primary care practice in Bucharest, especially the diagnostic and therapeutic attitudes of family doctors and their need for education and training in this field of pathology.
A questionnaire with 21specific questions was addressed to 800 family doctors from Bucharest ,either directly or via internet ,with a response rate of 31,87%.The answers showed a significant interest of GPs in drug allergies, which are considered an increasing pathology. Almost half of the responders had never attended any form of education in allergology and 96% expressed a clear interest to participate in specialized educational programmes. We have noticed an underestimation of the severity of drug allergy, a surprisingly high percentage of allergy skin tests or blood tests recommended by GPs without specialist advice, and persistant confidence in alternative medicine.
We concluded that the attitude towards and the competence regarding drug allergies of GPs in this study, as well as their collaboration with allergists, are not standardized and updated according to current guidelines. Further educational programs for GPs in drug allergies, based on standardized guidelines and national epidemiological studies for evaluation of drug allergy-related morbidity and mortality are needed.
... Despite guideline recommendations, the limited reviews available suggests that control of persistent asthma remains poor [28] with combination treatment being regarded as the most effective [29]. In view of this it is discouraging that only 44% of subjects with MSA and 22% of subjects with OA report use of a combination treatment, however, this is in line with other studies [28,30]. Those classified as having MSA used their medication more frequently and in higher doses than those classified as having OA. ...
Asthma medication was increasingly used during the second part of the past century. There are few detailed data from population studies on use of asthma medication. The current study aimed to determine the use and determinants of asthma medication in West Sweden and to assess changes during the last two decades.
From a random population sample participating in a survey on respiratory symptoms, 2000 individuals were randomly selected for clinical examinations and structured interviews, 1172 participated. All subjects reporting asthma (n=1524) were also invited, and 834 participated. In total, 964 subjects with asthma participated. Asthma medication use was assessed in the general population and among two severity categories of asthma: multi-symptom asthma (MSA) and "other" asthma (having fewer symptoms). Current data, from 2010, was compared with data from 1992. Asthma medication was used by 11% of the population, 4.4% used ICS with concurrent use of LABA, 3.3% used ICS without LABA, while 3.2% only used SABA. Compared with 1992, the prevalence of asthma medication use had increased with 54%, and use of ICS had increased from 1.5% to 7.7%. Subjects with MSA reported using asthma medication more frequently and at higher doses, and a higher proportion used ICS.
A shift in asthma medication use has occurred since 1992, with increased use of ICS and decreased use of SABA only, implying better asthma control on a population level. Multi-symptom asthma should alert the treating physician to consider under-medication and/or poor treatment adherence.
... We found that a considerable part of the subjects with partially controlled or uncontrolled asthma at follow-up (58% and 42%, respectively) was not following a therapy aimed at keeping asthma under control: such large proportions of subjects with partially controlled or uncontrolled asthma who were not using antiinflammatory drugs raise some concern. This evidence is supported from the results of an Italian study, where the authors found that Italian general practitioners did not use ICS to treat a large number of patients with persistent asthma [42]. Nevertheless, even a poor adherence to the GINA guidelines in asthma patients must be taken into account [43]. ...
Only few longitudinal studies on the course of asthma among adults have been carried out.
The aim of the present prospective study, carried out between 2000 and 2009 in Italy, is to assess asthma remission and control in adults with asthma, as well as their determinants.
All the subjects with current asthma (21-47 years) identified in 2000 in the Italian Study on Asthma in Young Adults in 6 Italian centres were followed up. Asthma remission was assessed at follow-up in 2008-2009 (n = 214), asthma control at baseline and follow-up. Asthma remission and control were related to potential determinants by a binomial logistic and a multinomial logistic model. Separate models for remission were used for men and women.
The estimate of the proportion of subjects who were in remission was 29.7% (95%CI: 14.4%;44.9%). Men who were not under control at baseline had a very low probability of being in remission at follow-up (OR = 0.06; 95%CI:0.01;0.33) when compared to women (OR = 0.40; 95%CI:0.17;0.94). The estimates of the proportion of subjects who were under control, partial control or who were not under control in our sample were 26.3% (95%CI: 21.2;31.3%), 51.6% (95%CI: 44.6;58.7%) and 22.1% (95%CI: 16.6;27.6%), respectively. Female gender, increasing age, the presence of chronic cough and phlegm and partial or absent asthma control at baseline increased the risk of uncontrolled asthma at follow-up.
Asthma remission was achieved in nearly 1/3 of the subjects with active asthma in the Italian adult population, whereas the proportion of the subjects with controlled asthma among the remaining subjects was still low.
... Some of this increase in risk is likely to come from shared factors, such as smoking [27] advanced age, decrease in physical activity, but chronic systemic inflammation could be pivotal. Indeed systemic inflammation is potentially the common pathway leading to the high prevalence of multiple chronic diseases in the same patient28293031. The chronicity of the inflammatory state is promoted by the production of several pro-inflammatory cytokines that increase in serum and in secretions of CVD and COPD patients323334. ...
The development of atherosclerosis is a multi-step process, at least in part controlled by the vascular endothelium function. Observations in humans and experimental models of atherosclerosis have identified monocyte recruitment as an early event in atherogenesis. Chronic inflammation is associated with ageing and its related diseases (e.g., atherosclerosis and chronic obstructive pulmonary disease). Recently it has been discovered that Sirtuins (NAD+-dependent deacetylases) represent a pivotal regulator of longevity and health. They appear to have a prominent role in vascular biology and regulate aspects of age-dependent atherosclerosis. Many studies demonstrate that SIRT1 exhibits anti-inflammatory properties in vitro (e.g., fatty acid-induced inflammation), in vivo (e.g., atherosclerosis, sustainment of normal immune function in knock-out mice) and in clinical studies (e.g., patients with chronic obstructive pulmonary disease). Because of a significant reduction of SIRT1 in rodent lungs exposed to cigarette smoke and in lungs of patients with chronic obstructive pulmonary disease (COPD), activation of SIRT1 may be a potential target for chronic obstructive pulmonary disease therapy. We review the inflammatory mechanisms involved in COPD-CVD coexistence and the potential role of SIRT1 in the regulation of these systems.
... However, in the ARGA study evaluating the impact of a single educational event on GP behavior in treating asthma and allergic rhinitis, no improvement in guideline adherence to guidelines in treating less severe rhinitis and asthma patients was seen, while there was a trend toward the opposite attitude in more severe AR patients without concomitant asthma. Multiple educational exposures might be a better choice to maximize retention and improve physician application of knowledge (17). ...
The standard of care for allergies within a primary care (PC) setting has a strong influence on disease prevention and control, quality of life, and patient satisfaction. The level of knowledge of allergic diseases and the accessibility to regular follow-up are essential. EAACI and IPCRG conducted a survey to evaluate the actual status of care for allergic diseases in PC. Access to allergy and asthma specialist treatment was identified as the greatest 'unmet need'. The average waiting time between a referral and being seen in a public health service is usually >6 weeks. Referring the patients to an 'organ' specialist is much easier compared with referral to an allergist. Most PCPs have access to blood tests for total and specific IgE. Skin prick testing is available in only half of the cases, while provocation tests, allergen quantification in homes, and a dietician service are even less available. 20.6% of practices do not have access to allergy tests at all. Other issues raised were low political or general public awareness, lack of understanding by the patients of their allergic disease, the need to invest in PC, and to achieve sufficient competence at the appropriate level of care.
... The ARGA study (Italian acronym for 'Respiratory Allergies: monitoring study for the application of GINA and ARIA guidelines'), funded by Agenzia Italiana del FArmaco (AIFA, Italian acronym for 'Italian Drug Agency'), was carried out between March 2007 and February 2010. The overall aim was to monitor how the World Health Organization GINA 14 and ARIA 2 guidelines for asthma and allergic rhinitis management are applied in clinical practice 15 . ...
Background:
General practitioners (GPs) are the healthcare professionals to whom patients with rhinitis firstly refer for their symptoms.
Objective:
In the present study, we assessed drug prescriptions for allergic rhinitis (AR) and evaluated prescriptive adherence to ARIA treatment guidelines.
Methods:
Data on 1379 AR patients were collected by 107 Italian GPs. Adherence to ARIA guidelines was evaluated according to AR severity classification.
Results:
AR was diagnosed by GPs as mild intermittent for 46.2% of patients, mild persistent for 26.6%, moderate-severe intermittent for 20.2%, and moderate-severe persistent for 7%; 43.7% of AR patients had concomitant asthma. The most frequently prescribed therapeutic groups were antihistamines (anti-H, 76%) and nasal corticosteroids (NCS, 46%). Anti-H were significantly used more often to treat AR alone than AR + asthma (85 vs. 68%, p < 0.001), whereas NCS were used more often to treat AR + asthma than AR alone (50 vs. 42%, p = 0.01). Among patients with only mild intermittent AR, 39% were prescribed combined therapy. Among patients with moderate-severe persistent AR, 30% of those with AR alone and 18% of those with AR + asthma were prescribed monotherapy based on anti-H. GPs were more compliant with ARIA guidelines while treating AR alone (57%) than AR + asthma (46%) patients. The adherence increased according to the severity grade and was satisfactory for moderate-severe persistent AR (89% for AR alone and 95% for AR + asthma).
Conclusions:
Adherence to ARIA guidelines is satisfactory only for treatment of more severe patients, thus GPs often tend to treat patients independently from ARIA guidelines. Since prescription data only provide limited information to judge prescribing quality, some deviation from the gold standard are to be expected.
Background. Since the start COVID-19 epidemic, 9154 deaths have been registered in Italian Long-Term Care Facilities (LTCF). Half of them were COVID 19-related.Objective. In this review we analyzed the management of COVID-19 outbreak in Italian LTCF, in the most affected regions. Results. In the Italian Institute of Health (ISS) report, 1356 LTCF (41.3%) answered to questionnaires on COVID-19 infection in LTCF. Only 7.4% of deaths was related to Coronavirus (confirmed by swab), while 33,8% of deceased presented flu-like symptoms without confirmation by swab. 77.2% of structures reported the lack of Personal Protective Equipment. The autonomous management policies of the regions cannot be negligible in this assessment, above all Lombardia Region that diverted patients from hospital to extra-structures, like LTCF. Conclusions. The elderlies represent high-risk patients for developing COVID-19 with rapid clinical deterioration. Containment measures should be particularly optimized, especially in anticipation of another possible pandemic recurrence. Surely a comparison among different systems could help to achieve more information in the standardization of procedures. Identifying flaws in this system is necessary to perfect and optimize epidemic management as much as possible.
Guidelines aim to standardize and optimize asthma diagnosis and management. Nevertheless, adherence to guidelines is suboptimal and may vary across different healthcare professional (HCP) groups.
Further to these concerns, this ERS/EAACI Statement aims (1) via an international online survey, to evaluate the understanding of and adherence to international asthma guidelines by HCPs of different specialties, (2) via systematic reviews, to assess strategies focused at improving implementation of guideline-recommended interventions, and compare process and clinical outcomes in patients managed by HCP of different specialties.
The online survey identified discrepancies between HCPs of different specialties which may be due to poor dissemination or lack of knowledge of the guidelines but also a reflection of the adaptations made in different clinical settings, based on available resources. The systematic reviews demonstrated that multifaceted quality improvement initiatives addressing multiple challenges to guidelines adherence are most effective in improving guidelines adherence. Differences in outcomes between patients managed by Generalists or Specialists should be further evaluated.
Guidelines need to consider the heterogeneity of real-life settings for asthma management and tailor their recommendations accordingly. Continuous, multifaceted quality improvement processes are required to optimize and maintain guidelines adherence. Validated referral pathways for uncontrolled asthma or uncertain diagnosis are needed.
Take home message: @EuroRespSoc @AllergyEAACI Statement: Guidelines need to account for differences in resource availability across various asthma care settings. Continuous, multifaceted quality improvement processes are needed to optimize and maintain guidelines adherence.
Background: Malnutrition is a frequent condition in the elderly and is associated with prolonged hospitalization and increased mortality. However, the impact of malnutrition among elderly patients with acute myocardial infarction has not been clarified yet. Methods and Results: We have enrolled 174 patients aged 65 years and over, admitted with the diagnosis of acute myocardial infarction (AMI) who underwent to the evaluation of nutritional status by Mini Nutritional Assessment (MNA) and of mortality risk by Grace score 2.0. All-cause mortality was the outcome considered for this study. Over a mean follow-up of 24.5 ± 18.2 months, 43 deaths have been registered (24.3%). Non-survivors were more likely to be older, with worse GFR, lower SBP, lower albumin and MNA score, higher prevalence of Killip classification III-IV grade, and higher Troponin I levels. Multivariate Cox proportional analysis revealed that Grace score and MNA showed a significant and independent impact on mortality, (HR = 1.76, 95% CI = 1.34–2.32 and HR = 0.56, 95% CI = 0.42–0.73, respectively). Moreover, the clinical decision curve revealed a higher clinical net benefit when the MNA was included compared to the partial models without MNA. Conclusions: Nutritional status is an independent predictor of long-term mortality among elderly patients with AMI. MNA score in elderly patients with AMI may help prognostic stratification and identification of patients with/at risk of malnutrition in order to apply interventions to improve nutritional status and maybe survival in this population.
Physical exercise is associated with reduced risk of heart disease, type II diabetes mellitus, and overall mortality. However, growing evidence shows that physical activity can also improve cognitive function and may lower the risk of developing dementia, but Randomized Clinical Trials gave mixed results. Aim of this article was to review the knowledge available in literature on the effects of physical activity on cognition and the suggested possible mechanisms involved in these effects. Our group have planned a trial aiming to evaluate the effectiveness of physical activity in preventing or delaying the cognitive decline in individuals at risk of developing dementia. Beside the effects of exercise on cognition are not fully defined, also the mechanisms underlying the benefits of physical activity on cognitive sphere are not completely known. Recently the SIRT1 loss is both closely associated with accumulation of beta amyloid and tau protein in AD patients. Although there is no specific exercise that can be recommended, the available evidence suggests that practicing more types of physical activity is particularly advantageous. It is important to explore further mechanisms involved in the pathogenesis of the AD in order to be able to identify new and effective target treatment, including physical activity.
Allergic rhinitis is a significant disease that adversely affects quality of life. Guidelines for diagnosis and management of allergic rhinitis are simple, yet not widely implemented. In addition, there are nuances in diagnosis and management that may make the treatment of allergic rhinitis very challenging. Education is recommended as a key strategy for management of allergic rhinitis, yet data on patient education in allergic rhinitis is fragmented. Leaflets for education are often inadequate. Educational programs, that include holistic training about allergic rhinitis, are more effective than those focussing on techniques of administration of intranasal medication only. However, there is no consensus on what those programs should contain or how to administer them. Educational strategies for allergic rhinitis may benefit from adopting some of the strategies proven to be effective in asthma education, such as the adoption of specific key messages around symptoms and control of rhinitis that change patients' expectations of their disease. A focus on pathophysiology of different aspects of rhinitis symptoms may foster adherence to regular anti-inflammatory therapy. Essential aspects of a management plan may include the central role of allergic and non-allergic triggers, pre-empting patients' concern regarding medication and detailed training in the technique of administration of nasal spray.
Clinical practice guidelines aim to improve the quality of patient care by providing specific recommendations for daily practice. Many factors may influence the implementation of a guideline in practice. An adequate analysis of the barriers to guideline adherence can help to improve it's implementation.
Despite the proven efficacy of the National Heart, Lung, and Blood Institute asthma guidelines, adherence to these recommendations is suboptimal among primary care physicians. Knowledge, skills, and attitudes among pediatricians influence adherence to the asthma guidelines. Workshop-based provider education interventions demonstrate short-term improvement in knowledge, but do not lead to long-term changes in patient outcomes. Comprehensive quality improvement interventions that integrate education and process changes yield the best results in improving asthma care in children.
Objective. Asthma is a disease with elevated prevalence within the general population. Although general practitioners (GPs) are among the first health-care professionals to whom patients refer for their symptoms, there are few evaluations of this disease based on data provided by the GPs. The aim of this observational study is to assess the impact of asthma and comorbid allergic rhinitis on individual/social burden, quality of life, and disease control in asthmatic patients of Italian GPs. Methods. Throughout Italy, 107 GPs enrolled 995 patients diagnosed with asthma and using anti-asthmatic drug prescriptions, or with asthma-like symptoms during the previous 12 months. Data were collected through questionnaires filled out by GPs and patients. Results. Of the 995 asthmatic patients, 60.6% had concomitant allergic rhinitis (R+A), 39.4% had asthma alone. The latter, compared to those with R+A, showed significantly lower prevalence of intermittent asthma (37.5% vs. 55.6%) and higher prevalence of mild, moderate, and severe persistent asthma (28.4% vs. 23.2%, 28.7% vs. 18.8%, and 5.4% vs 2.4%, respectively). Individual/social burden due to asthma was frequent and increased with disease severity: 87.5% of severe persistent asthma patients reported at least one medical consultation in the last 12 months, 37.5% emergency department visits, 26.7% hospitalization, and 62.5% limitations in daily activities. Control and quality of life were inversely associated with disease severity and were worse in patients with R+A than in those with asthma alone. Conclusions. This study showed the negative impact of high severity levels and comorbid allergic rhinitis on quality of life of asthmatic patients and on individual/social burden due to asthma in an Italian GPs setting.
Context:
Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behavior. Little is known about the process and factors involved in changing physician practices in response to guidelines.
Objective:
To review barriers to physician adherence to clinical practice guidelines.
Data sources:
We searched the MEDLINE, Educational Resources Information Center (ERIC), and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks on health behavior or public health; and references supplied by experts to find English-language article titles that describe barriers to guideline adherence.
Study selection:
Of 5658 articles initially identified, we selected 76 published studies describing at least 1 barrier to adherence to clinical practice guidelines, practice parameters, clinical policies, or national consensus statements. One investigator screened titles to identify candidate articles, then 2 investigators independently reviewed the texts to exclude articles that did not match the criteria. Differences were resolved by consensus with a third investigator.
Data extraction:
Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes, or behavior. This organization was validated by 3 additional investigators.
Data synthesis:
The 76 articles included 120 different surveys investigating 293 potential barriers to physician guideline adherence, including awareness (n = 46), familiarity(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14), and absence of external barriers to perform recommendations (n = 34). The majority of surveys (70 [58%] of 120) examined only 1 type of barrier.
Conclusions:
Studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another. Our review offers a differential diagnosis for why physicians do not follow practice guidelines, as well as a rational approach toward improving guideline adherence and a framework for future research.
To evaluate the response and survival rate after three-dimensional conformal radiation therapy
(3D-CRT) of patients with a solitary sternal relapse of breast cancer.
To cite this article: Bousquet J, Schünemann HJ, Zuberbier T, Bachert C, Baena‐Cagnani CE, Bousquet PJ, Brozek J, Canonica GW, Casale TB, Demoly P, Gerth van Wijk R, Ohta K, Bateman ED, Calderon M, Cruz AA, Dolen WK, Haughney J, Lockey RF, Lötvall J, O’Byrne P, Spranger O, Togias A, Bonini S, Boulet LP, Camargos P, Carlsen KH, Chavannes NH, Delgado L, Durham SR, Fokkens WJ, Fonseca J, Haahtela T, Kalayci O, Kowalski ML, Larenas‐Linnemann D, Li J, Mohammad Y, Mullol J, Naclerio R, O’Hehir RE, Papadopoulos N, Passalacqua G, Rabe KF, Pawankar R, Ryan D, Samolinski B, Simons FER, Valovirta E, Yorgancioglu A, Yusuf OM, Agache I, Aït‐Khaled N, Annesi‐Maesano I, Beghe B, Ben Kheder A, Blaiss MS, Boakye DA, Bouchard J, Burney PG, Busse WW, Chan‐Yeung M, Chen Y, Chuchalin AG, Costa DJ, Custovic A, Dahl R, Denburg J, Douagui H, Emuzyte R, Grouse L, Humbert M, Jackson C, Johnston SL, Kaliner MA, Keith PK, Kim YY, Klossek JM, Kuna P, Le LT, Lemiere C, Lipworth B, Mahboub B, Malo JL, Marshall GD, Mavale‐Manuel S, Meltzer EO, Morais‐Almeida M, Motala C, Naspitz C, Nekam K, Niggemann B, Nizankowska‐Mogilnicka E, Okamoto Y, Orru MP, Ouedraogo S, Palkonen S, Popov TA, Price D, Rosado‐Pinto J, Scadding GK, Sooronbaev TM, Stoloff SW, Toskala E, van Cauwenberge P, Vandenplas O, van Weel C, Viegi G, Virchow JC, Wang DY, Wickman M, Williams D, Yawn BP, Zar HJ, Zernotti M, Zhong N, In collaboration with the WHO Collaborating Center of Asthma and Rhinitis (Montpellier). Development and implementation of guidelines in allergic rhinitis – an ARIA‐GA ² LEN paper. Allergy 2010; 65 : 1212–1221.
Abstract
The links between asthma and rhinitis are well characterized. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines stress the importance of these links and provide guidance for their prevention and treatment. Despite effective treatments being available, too few patients receive appropriate medical care for both diseases. Most patients with rhinitis and asthma consult primary care physicians and therefore these physicians are encouraged to understand and use ARIA guidelines. Patients should also be informed about these guidelines to raise their awareness of optimal care and increase control of the two related diseases. To apply these guidelines, clinicians and patients need to understand how and why the recommendations were made. The goal of the ARIA guidelines is to provide recommendations about the best management options for most patients in most situations. These recommendations should be based on the best available evidence. Making recommendations requires the assessment of the quality of available evidence, deciding on the balance between benefits and downsides, consideration of patients' values and preferences, and, if applicable, resource implications. Guidelines must be updated as new management options become available or important new evidence emerges. Transparent reporting of guidelines facilitates understanding and acceptance, but implementation strategies need to be improved.
To assess the standard of asthma management by doctors in Hong Kong.
Cross-sectional postal questionnaire survey.
Hong Kong.
Practising doctors registered with the Medical Council of Hong Kong were sent a questionnaire between August and December 2007.
Respondents' responses to questions on demographic data, parameters routinely used to assess asthma control, the pattern of asthma medication prescribing, and seven different case scenarios assessing their ability to classify asthma control and management. RESULTS. We received 410 completed questionnaires from general practitioners (55%), internists (22%), paediatricians (11%), and other specialists (12%). The majority (82%) explained the pathology of asthma to at least some of their patients and tried to identify aggravating factors of the asthma (91%). Fewer observed the inhalation technique of their patients (68%) and prescribed a written asthma management plan (33%). The main medications prescribed to adults and children with asthma were inhaled corticosteroids, inhaled short-acting beta-2 agonists, and combinations of an inhaled corticosteroid and a long-acting beta-2 agonist. In adults and children, long-acting beta-2 agonist alone (without inhaled corticosteroid) was being used to treat asthma by 45% and 36% of the doctors, respectively. Also, 94% of the respondents correctly classified the control status in four out of the seven case scenarios and 31% chose the correct medications when responding to seven of the 14 questions asked.
Asthma management practice of Hong Kong doctors falls short of the standards recommended by international guidelines. More effort in improving their knowledge is urgently warranted.
Allergic rhinitis is a global health problem. Over 600 million patients suffer from this disease worldwide. ARIA (Allergic Rhinitis and its Impact on Asthma), an evidence-based document, was produced and published in 2001 using an extensive review of the available literature. The ARIA 2008 update was recently published and covers tertiary prevention of allergy, pharmacologic treatments, and immunotherapy. Nonallergic rhinitis is still a controversial area and may pose some treatment problems. Another important aspect of the ARIA update is the comorbidity of allergic rhinitis, in particular, asthma. The recommendations of the 2008 ARIA Update, as in 2001, are that patients with allergic rhinitis, particularly if persistent, should be evaluated for asthma, patients with asthma should be evaluated for rhinitis, and an effective and safe combination strategy should be used to treat diseases of the upper and lower airways. Over the last few years, severa studies performed in Spain report new data on the prevalence of allergic rhinitis sensitivity to common aeroallergens, comorbidity of allergic rhinitis and asthma, and impact on quality of life. The studies reviewed in this manuscript confirm--as do those from other developed countries--the enormous impact of the disease on society and health care in Spain.
The aim of this study was to determine the spreading level of the WHO-ARIA (World Health Organization's Allergic Rhinitis and its Impact on Asthma) guidelines among the medical community and their influence on medical practices.
A cross-sectional study based on a questionnaire was performed between April and July 2005 on randomly chosen general practitioners (GPs) (943) and ear, nose and throat (ENT) physicians (277).
About 54.4% of the physicians claimed to know the WHO-ARIA guidelines and 49.7% said they followed them. These results vary significantly, mainly according to medical specialty (ENT vs. GP). In comparison to those who did not know the guidelines, their patients benefited more frequently (P<0.0001) from allergen search (42.2% vs. 31.7%), a nasal endoscopy (38.3% vs. 26.0%), a follow-up consultation (64.9% vs. 52.6%) and written information on rhinitis (30.7% vs. 14.1%). Paradoxically, they do not search more frequently for asthma and do not provide different first-line treatment strategy and duration.
Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behavior. Little is known about the process and factors involved in changing physician practices in response to guidelines.
To review barriers to physician adherence to clinical practice guidelines.
We searched the MEDLINE, Educational Resources Information Center (ERIC), and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks on health behavior or public health; and references supplied by experts to find English-language article titles that describe barriers to guideline adherence.
Of 5658 articles initially identified, we selected 76 published studies describing at least 1 barrier to adherence to clinical practice guidelines, practice parameters, clinical policies, or national consensus statements. One investigator screened titles to identify candidate articles, then 2 investigators independently reviewed the texts to exclude articles that did not match the criteria. Differences were resolved by consensus with a third investigator.
Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes, or behavior. This organization was validated by 3 additional investigators.
The 76 articles included 120 different surveys investigating 293 potential barriers to physician guideline adherence, including awareness (n = 46), familiarity(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14), and absence of external barriers to perform recommendations (n = 34). The majority of surveys (70 [58%] of 120) examined only 1 type of barrier.
Studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another. Our review offers a differential diagnosis for why physicians do not follow practice guidelines, as well as a rational approach toward improving guideline adherence and a framework for future research.
Between one third and half of all consultations result in a prescription, and general practitioners are responsible for more than 80 per cent of the use of reimbursed prescription drugs in Denmark. Good prescribing habits imply the use of a limited number of drugs of which the doctor has a good knowledge. The risk of inappropriate prescribing is higher among doctors who prescribe many different drugs. The prescribing habits of the individual physician are quite stable, and changes usually occur slowly and as a result of various influences, including scientific papers, specialist recommendations, meetings, colleagues, patients, and drug companies. Previous development initiatives were often based on the assumption that suboptimal prescribing practice was due to lack of knowledge. It was, thus, expected that easily understandable information alone could improve the prescribing in general practice. However, continuous medical education based on didactic methods such as lectures and clinical guidelines have proved ineffective. Quality development should include thorough problem identification and analysis, elucidation of barriers towards change, and a combination of several targeted interventions. The implementation of changes should be seen as a complex, slowly progressing process in which continuous evaluation should be carried out with a view to adjusting the interventions.
To estimate the prevalence of respiratory disorders in children, and to investigate the roles of potential environmental risk factors, including exposure to outdoor air pollution, a large multicenter, population based survey (SIDRIA) was conducted in Italy in 1994-1995. The study enrolled more than 40,000 children. Results allowed international comparisons of the prevalences of asthma and allergies in childhood in the framework of the ISAAC (International Study of Asthma and Allergies in Childhood) study, and supplied further evidence of the adverse respiratory effects of many environmental factors. The methods and main findings of the SIDRIA study are presented, focusing on the role of outdoor risk factors.
The guidelines for asthma recommend that the use of anti-inflammatory therapy should be adapted to the severity of the disease. However, few data are available to assess the adequacy of the use of drugs and its influence on the control of asthma in 'real life'.
The adequacy of the current use of anti-asthmatic medication according to the Global Initiative for Asthma (GINA) guidelines was assessed in a random sample of 400 asthmatics identified in the frame of the Italian Study on Asthma in Young Adults. Asthma severity was assessed using the GINA criteria; accordingly, a patient was classified as receiving inadequate treatment if his/her current use of drugs was lower than that suggested by the guidelines for the corresponding severity level. The absence of asthma attacks in the last 3 months was used as an indicator of the disease control.
Fifty-five percent of the patients had persistent asthma. Overall, 48% (95% CI 41.2-54.8) of persistent asthmatics were receiving inadequate treatment, and 66% (95% CI 59.5-72.4) had not used their medication daily over the past 3 months. Persistent asthmatics who were inadequately treated had a significantly greater frequency of asthma attacks (geometric mean ratio 3.7; 95% CI 2.1-6.6) than those using an adequate dose of medication. Mild and moderate persistent asthmatics using an adequate medication regimen reported a low number of asthma attacks (median 0). At the multivariate analysis, a good control of the disease was positively associated with an adequate dose of anti-inflammatory medication (OR = 2.2; 95% CI 1.1-4.5) and was negatively associated with a later onset of asthma (OR = 0.96; 95% CI 0.93-0.99) and severe asthma (OR = 0.37; 95% CI 0.17-0.81).
Despite the increase in the use of inhaled corticosteroids, half of the persistent asthmatics from the general population are using a medication regimen below their severity level. When the use of drugs follows the GINA guideline recommendations, a good control of asthma is also achievable in the daily management of the disease, particularly in the case of mild and moderate asthmatics.
It is difficult to keep control over prescribing behaviour in general practices. The purpose of this study was to assess the effects of a dissemination strategy of multidisciplinary guidelines on the volume of drug prescribing.
The study included two designs, a quasi-experimental pre/post study with concurrent control group and a random sample of GPs within the intervention group. The intervention area with 53 GPs was compared with a control group of 54 randomly selected GPs in the south and centre of the Netherlands. Additionally, a randomisation was executed in the intervention group to create two arms with 27 GPs who were more intensively involved in the development of the guideline and 26 GPs in the control group. A multidisciplinary committee developed prescription guidelines. Subsequently these guidelines were disseminated to all GPs in the intervention region. Additional effects were studied in the subgroup trial in which GPs were invited to be more intensively involved in the guideline development procedure. The guidelines contained 14 recommendations on antibiotics, asthma/COPD drugs and cholesterol drugs. The main outcome measures were prescription data of a three-year period (one year before and 2 years after guideline dissemination) and proportion of change according to recommendations.
Significant short-term improvements were seen for one recommendation: mupirocin. Long-term changes were found for cholesterol drug prescriptions. No additional changes were seen for the randomised controlled study in the subgroup. GPs did not take up the invitation for involvement.
Disseminating multidisciplinary guidelines that were developed within a region, has no clear effect on prescribing behaviour even though GPs and specialists were involved more intensively in their development. Apparently, more effort is needed to bring about change.
Allergic rhinitis and asthma are both chronic heterogeneous disorders, with an overlapping epidemiology of prevalence, health care costs and social costs in quality of life. Both are inflammatory disorders with a similar pathophysiology, and both share some treatment approaches. However, each disorder has an array of treatments used separately in controlling these atopic disorders, from inhaled corticosteroids, beta
2
-agonists and antihistamines to newer monoclonal antibody-based treatments. The present article reviews the shared components of allergic rhinitis and asthma, and examines recent evidence supporting antileukotrienes as effective agents in reducing the symptoms of both diseases.
Allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the membranes lining the nose. It is a global health problem that causes major illness and disability worldwide. Over 600 million patients from all countries, all ethnic groups and of all ages suffer from allergic rhinitis. It affects social life, sleep, school and work and its economic impact is substantial. Risk factors for allergic rhinitis are well identified. Indoor and outdoor allergens as well as occupational agents cause rhinitis and other allergic diseases. The role of indoor and outdoor pollution is probably very important, but has yet to be fully understood both for the occurrence of the disease and its manifestations.
In 1999, during the Allergic Rhinitis and its Impact on Asthma (ARIA) WHO workshop, the expert panel proposed a new classification for allergic rhinitis which was subdivided into 'intermittent' or 'persistent' disease.
This classification is now validated. The diagnosis of allergic rhinitis is often quite easy, but in some cases it may cause problems and many patients are still under-diagnosed, often because they do not perceive the symptoms of rhinitis as a disease impairing their social life, school and work.
The management of allergic rhinitis is well established and the ARIA expert panel based its recommendations on evidence using an extensive review of the literature available up to December 1999. The statements of evidence for the development of these guidelines followed WHO rules and were based on those of Shekelle et al. A large number of papers have been published since 2000 and are extensively reviewed in the 2008 Update using the same evidence-based system. Recommendations for the management of allergic rhinitis are similar in both the ARIA workshop report and the 2008 Update. In the future, the GRADE approach will be used, but is not yet available.
Another important aspect of the ARIA guidelines was to consider co-morbidities. Both allergic rhinitis and asthma are systemic inflammatory conditions and often co-exist in the same patients. In the 2008 Update, these links have been confirmed.
The ARIA document is not intended to be a standard-of-care document for individual countries. It is provided as a basis for physicians, health care professionals and organizations involved in the treatment of allergic rhinitis and asthma in various countries to facilitate the development of relevant local standard-of-care documents for patients.
The links between asthma and rhinitis are well characterized. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines stress the importance of these links and provide guidance for their prevention and treatment. Despite effective treatments being available, too few patients receive appropriate medical care for both diseases. Most patients with rhinitis and asthma consult primary care physicians and therefore these physicians are encouraged to understand and use ARIA guidelines. Patients should also be informed about these guidelines to raise their awareness of optimal care and increase control of the two related diseases. To apply these guidelines, clinicians and patients need to understand how and why the recommendations were made. The goal of the ARIA guidelines is to provide recommendations about the best management options for most patients in most situations. These recommendations should be based on the best available evidence. Making recommendations requires the assessment of the quality of available evidence, deciding on the balance between benefits and downsides, consideration of patients' values and preferences, and, if applicable, resource implications. Guidelines must be updated as new management options become available or important new evidence emerges. Transparent reporting of guidelines facilitates understanding and acceptance, but implementation strategies need to be improved.
To describe the economic burden of allergic rhinitis treatment and current guidelines for treatment.
Review articles and original research were retrieved from MEDLINE, OVID, PubMed (1950-November 2009), personal files of articles, and bibliographies of located articles that addressed the topic of interest.
Articles were selected for their relevance to the burden of allergic rhinitis and current guidelines for treatment. Publications included reviews, treatment guidelines, and clinical studies.
Despite the common symptoms of allergic rhinitis, its impact on patient quality of life, and the huge cost to society and individuals of treatment, including pharmacotherapy, many patients do not adhere to their medication regimens because the medications do not adequately address their symptoms or are otherwise problematic for them to use.
The economic impact of allergic rhinitis is substantial; the total direct medical cost of allergic rhinitis is approximately $3.4 billion, with almost half of this cost attributable to prescription medications. Multiple treatment options are available, and these were reviewed to provide an update on effectiveness and adverse effects that may affect patient adherence.
Asthma is a chronic disease characterized by airway inflammation and hyperresponsiveness and is associated with significant yet avoidable mortality and morbidity resulting in considerable individual and societal burden. Inhaled corticosteroids are the most effective class of controller medication available today for treating persistent asthma and are the evidence-based guideline-recommended first-line treatment for controlling asthma. Although inhaled corticosteroids have proven to reduce asthma-related exacerbations that lead to hospitalizations and death, recent studies have shown that only a small percentage of patients receive appropriate treatment and monitoring for their asthma. Delivering optimal asthma management requires an understanding and application of basic science and evidence-based guidelines in clinical practice. Management of a chronic disease in the primary care setting requires overcoming several barriers due to competing priorities and time constraints of the physician, as well as the reluctance of patients to actively participate in their own care. However, evidence has shown that the patient-centered medical home model can overcome some of these issues and improve patient outcomes and adherence to therapy.
Allergic rhinitis represents a global health problem affecting 10% to 20% of the population. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines have been widely used to treat the approximately 500 million affected patients globally.
To develop explicit, unambiguous, and transparent clinical recommendations systematically for treatment of allergic rhinitis on the basis of current best evidence.
The authors updated ARIA clinical recommendations in collaboration with Global Allergy and Asthma European Network following the approach suggested by the Grading of Recommendations Assessment, Development and Evaluation working group.
This article presents recommendations about the prevention of allergic diseases, the use of oral and topical medications, allergen specific immunotherapy, and complementary treatments in patients with allergic rhinitis as well as patients with both allergic rhinitis and asthma. The guideline panel developed evidence profiles for each recommendation and considered health benefits and harms, burden, patient preferences, and resource use, when appropriate, to formulate recommendations for patients, clinicians, and other health care professionals.
These are the most recent and currently the most systematically and transparently developed recommendations about the treatment of allergic rhinitis in adults and children. Patients, clinicians, and policy makers are encouraged to use these recommendations in their daily practice and to support their decisions.
In 2001, the ARIA guidelines were published to assist healthcare practitioners in managing allergic rhinitis (AR) according to the best evidence. Very limited information, however, is avail-able on the impact of these guidelines on clinical practice.
All Belgian Otorhinolaryngologists were invited to complete a questionnaire, covering demographic and professional characteristics, knowledge, use and perception of the ARIA guidelines and 4 clinical case scenarios of AR.
Of the 258 (44%) Belgian Otorhinolaryngologists who participated, almost 90% had ever heard about ARIA and 64% had followed a lecture specifically dedicated to the ARIA guidelines. Furthermore, 62% stated to always or mostly follow the ARIA treatment algorithms in the daily management of AR patients. In the clinical case section, adherence to the ARIA guidelines raised with increased self-reported knowledge and use of the ARIA guidelines and among participants that considered the guidelines more userfriendly. Of the respondents, 51% were considered as good com-pliers. Younger age was a significant predictor for good compliance.
More efforts are required to improve the translation of scientific knowledge into clinical practice and to further identify which factors may influence guideline compliance.
Combination inhaled corticosteroid and long-acting beta(2)-adrenergic agonist (ICS/LABA) therapy is recommended for patients whose asthma is not adequately controlled by other maintenance therapies and for those with moderate to severe asthma.
This study examined the appropriateness of initiation of ICS/LABA combination therapy based on health care use criteria and the proportions of US patients filling prescriptions for either of 2 available therapies.
This retrospective cohort study analyzed data from commercially insured asthma patients aged 12 to 64 years who initiated combination therapy with fluticasone propionate/salmeterol (FSC) or budesonide/ formoterol fumarate dihydrate (BFC) from July 1, 2007, to June 30, 2008. Continuously enrolled patients who had not received ICS/LABA therapy during a 12-month preindex period were assigned to the BFC or FSC cohort based on their initial ICS/LABA prescription (index date). Appropriate initiation of ICS/LABA combination therapy was determined based on the risks for asthma exacerbation, high impairment, and previous controller medication use. Specifically, initiation of ICS/LABA therapy was considered appropriate if patients had claims during the preindex period for an ICS or leukotriene receptor antagonist, an asthma-related emergency department visit or hospitalization, >or=2 courses of oral corticosteroid, or >or=6 canisters of a rescue short-acting beta(2)-adrenergic agonist (SABA). Factors associated with appropriate initiation of ICS/LABA therapy were assessed by multivariate logistic regression.
Of 16,205 patients initiated on ICS/LABA therapy, 39.2% met >or=1 criterion for appropriate use-788 of 1417 patients (55.6%) in the BFC group and 5572 of 14,788 patients (37.7%) in the FSC group (P < 0.001). Significantly greater proportions of BFC than FSC users met the individual criteria for previous controller medication use (45.7% vs 26.1%, respectively) and high SABA use (9.7% vs 6.1%). BFC users had a significantly higher likelihood of meeting >or=1 appropriateness criterion compared with FSC users (odds ratio = 1.79; 95% CI, 1.60-2.00; P < 0.001). Also significantly associated with appropriate use were receipt of the initial ICS/LABA prescription from a pulmonologist or allergist rather than from a physician in family medicine/general practice (P < 0.001), residence in the West relative to the Northeast (P < 0.005), and presence of specific comorbidities (allergic rhinitis, sinusitis, gastroesophageal reflux disease, and acute respiratory infection; all, P < 0.001).
Just under 40% of patients met the criteria for appropriate initiation of ICS/LABA therapy, with significantly greater proportions of BFC than FSC users meeting the overall and individual criteria for appropriate use. Patients with appropriate initiation of ICS/LABA therapy were significantly more likely to be treated by pulmonologists and allergists than by family medicine/general practitioners.
Rhinitis is the most frequent respiratory disease in most countries of the world. It is estimated that 600 million people suffer this condition. Allergic rhinitis is a public health problem at global level. Patients who suffer allergic rhinitis have from mild to annoying nasal symptoms which affect quality of life, cause sleep disorders, scholar and workplace absenteeism, and health expenditure. Rhinitis is frequently associated to co-morbidities such as sinusitis, otitis media, and especially asthma. Rhinitis is under-diagnosed and under-treated worldwide and also in Latin American countries. ARIA is the very first evidence-based guideline for the diagnosis and treatment of rhinitis with focus in its co-morbidities (2001), especially asthma published in 2001. In 2008 an update was published. ARIA recommends an integrative approach for management; including anti-histamines (second generation), intra-nasal corticosteroids, anti-leukotrienes and immunotherapy. It also provides a questionnaire to evaluate asthma and its severity in those patients suffering rhinitis. The prevalence of allergic rhinitis is quite high in Latin American countries and in recent years a great insight on the burden of this condition has been gained.
Clinical Practice Guidelines for allergic rhinitis have been developed over the past 15 years and have been found to improve the care for patients with allergic rhinitis. The ARIA (allergic rhinitis and its impact on asthma) guideline was the first of these evidenced-based guidelines, developed with primary care physicians. Subsequent guidelines include those by the IPCRG, BSACI, the AAAAI/ACAAI Practice Parameters for the diagnosis and management of rhinitis, and the ARIA 2008 Update. These guidelines were based on various evidencebased models, but the first to use GRADE methodology (Grading of Recommendations Assessment, Development and Evaluation) is the ARIA 2009 Revision. Since primary care physicians treat the majority of patients with allergic rhinitis it is essential that they are involved in the development and implementation of guidelines for allergic rhinitis. Prior to their implementation, guidelines should be evaluated for their accuracy and user friendliness - specifically for primary care physicians - but such validation is rarely performed. This is of great importance, in particular as regards evaluating the applicability of evidence from high quality randomised controlled trials (RCTs) which are often based on highly selected patients not representing the population of patients seen in day-to-day practice.
There has been sizable debate and widespread skepticism about the effect of continuing medical education (CME) on the performance of physicians in the practice setting. This portion of the review was undertaken to examine that effect.
The guideline panel used data from a comprehensive review of the effectiveness of CME developed by The Johns Hopkins Evidence-based Practice Center, focusing on the effect of CME on clinical performance.
The review found 105 studies, which evaluated the impact of CME on short- and long-term physician practice performance. Nearly 60% met objectives relative to changing clinical performance in prescribing; screening; counseling about smoking cessation, diet, and sexual practices; guideline adherence; and other topics. Single live and multiple media appeared to be generally positive in their effect, print media much less so. Multiple educational techniques were more successful at changing provider performance than single techniques. The amount or frequency of exposure to CME activities appeared to have little effect on behavior change.
Overall, CME, especially using live or multiple media and multiple educational techniques, is generally effective in changing physician performance. More research, however, is needed that focuses on the specific types of media and educational techniques that lead to the greatest improvements in performance.
Recommendations for optimizing continuing medical education (CME) effectiveness in improving physician application of knowledge and psychomotor skills are needed to guide the development of processes that effect physician change and improve patient care.
The guideline panel reviewed evidence tables and a comprehensive review of the effectiveness of CME developed by The Johns Hopkins Evidence-based Practice Center for the Agency for Healthcare Research and Quality (AHRQ Evidence Report). The panel considered studies relevant to the effect of CME on physician knowledge application and psychomotor skill development. From the 136 studies identified in the systematic review, 15 articles, 12 addressing physician application of knowledge and 3 addressing psychomotor skills, were identified and reviewed. Recommendations for optimizing CME were developed using the American College of Chest Physicians guideline grading system.
The preponderance of evidence demonstrated improvement in physician application of knowledge with CME. The quality of evidence did not allow specific recommendations regarding optimal media or educational techniques or the effectiveness of CME in improving psychomotor skills.
CME is effective in improving physician application of knowledge. Multiple exposures and longer durations of CME are recommended to optimize educational outcomes.
To improve prescribing practices for rhinopharyngitis, an interactive educational intervention and a managerial intervention were carried out in 18 primary care facilities in metropolitan Mexico City. Four family medicine clinics of the Mexican Social Security Institute (IMSS) and 14 health centres of the Ministry of Health (SSA) were included. A quasi-experimental design was employed. One hundred and nineteen physicians (IMSS 68, SSA 51) participated. Sixty-five physicians (IMSS 32, SSA 33) were in the study group, while 54 were in the control group (IMSS 36, SSA 18). The study had four stages: (I) baseline, to evaluate the physicians' prescribing behaviour for rhinopharyngitis; (II) intervention, using an interactive educational workshop and a managerial peer review committee; (III) post-intervention evaluation of short-term impact; and (IV) follow-up evaluation of long-term effect 18 months after the workshop. The control group did not receive any intervention but was evaluated at the same time as the study group. At baseline, most patients in both institutions received antibiotic prescriptions (IMSS 85.2%, SSA 68.8%). After the workshop, the percentage of patients receiving antibiotic prescriptions in the IMSS went from 85.2% to 48.1%, while in the SSA it went from 68.8% to 49.1%. Appropriateness of treatment was analyzed using the physician as the unit of analysis. At baseline, 30% of IMSS physicians in the study group treated their patients appropriately. After the intervention, this percentage increased to 57.7%, and at the 18-month follow-up it was 54.2%. The SSA study group increased the appropriate use of antibiotics from 35.7% to 46.2%, with this percentage falling to 40.9% after the 18-month follow-up period. In the control group there were no significant changes in prescribing patterns with respect to either the prescribing of antibiotics or the appropriateness of treatment. The intervention strategies were successful in both institutions. Forty per cent of physicians improved their prescribing practices after the workshop, with this change remaining in 27.5% of them throughout the follow-up period. On the other hand, 42.5% of the physicians did not change their prescribing practices after the intervention. The rest (17.5%) showed appropriate prescribing practices during all the stages of the study. We conclude that it is possible to improve the physicians' prescribing practices through interactive educational strategies and managerial interventions. This type of intervention can be an affordable way to provide continuing medical education to primary care physicians who do not have access to continuing educational activities, and to improve the quality of care they provide.
Adherence to asthma practice guidelines is low. Improved compliance could potentially improve care of patients with asthma. The purpose of this study was to determine if patients managed in a general practice with an associated asthma clinic are more likely to use asthma medications according to clinical practice guidelines than patients managed in the general surgery of the practice. A cross-sectional study of adult asthmatics, aged 18-55 years, was conducted in six British general practices. Prescription data on all asthma medication was collected for a 6-month period. Information on asthma clinic attendance, age, sex, employment status, other medical illness, and how patients used their inhaled beta2-agonist was collected through questionnaire. The prescription data for asthma medication and patient use of inhaled beta2-agonist were compared to the British Thoracic Society's (BTS) Guidelines for Management of Asthma in Adults to determine if the patient's asthma medication regimen was appropriate. There was no significant association found between appropriate asthma medication and asthma clinic attendance or other patient characteristics. Adherence to the BTS guidelines was low. Fifty-eight percent of the asthma patients used asthma medication regimens that were not consistent with the BTS guidelines published 1 year earlier. Adherence to the BTS guidelines was low regardless of patient characteristics, including asthma clinic attendance, age, sex, employment status, other medical illness, or individual practice. These findings underscore the need to document the utility of clinical practice guidelines which may improve physician compliance.
Failure to follow asthma management guidelines may result in poor asthma control for many patients. The Asthma Insights and Reality in Europe (AIRE) survey, a multi-national survey assessing the level of asthma control from the patients perspective in seven Western European countries, previously demonstrated that the Global Initiative for Asthma (GINA) guideline goals were not achieved in Western Europe and that both adults and children with asthma were poorly controlled. Using additional data on asthma management practices from each of the seven countries in the AIRE survey, we compared variations in asthma morbidity and asthma management practices across countries to provide insight into the reasons for poor asthma control. Asthma management practices and asthma control among adults and children with current asthma were suboptimal in each of seven countries surveyed. Among patients with symptoms of severe persistent asthma, over 40% reported their asthma was well or completely controlled. School absence due to asthma was reported by upto 52.7% of children and up to 27.6% of adult reported work absence due to asthma. Lung function testing in the past year was uncommon: ranging from 13.5% of children in the U.K. to 68.8% of adults in Germany. Written asthma management plans were used by less than 50% of adults and less than 61% of children in all seven countries. Most adults (49.5-73.0%) and a large proportion of children (38.4-70.6%) had follow-up visits for their asthma only when problems developed. The ratio of recent inhaled corticosteroid use to recent short-acting beta-agonist use was inappropriate (<1) among patients with symptoms of severe asthma in all countries. This disparity was greatest among adults in Italy and France, where recent inhaled corticosteroid use was reported by less than one in nine patients reporting recent use of short-acting bronchodialators (IS:SAB <0.11). Management practices differ between countries and additional public health interventions and resources may be necessary to reduce patient suffering. Further efforts to fully implement asthma management guidelines are required to improve asthma control in Europe.
Teaching university hospital in Karachi, Pakistan.
Asthma management guidelines have been developed to assist practising physicians in treating asthma patients. The objective of this study was to evaluate if the prescribing habits of practitioners in Karachi were consistent with the published asthma guidelines.
A questionnaire survey was conducted among practitioners attending a pulmonary continuing medical education (CME) programme. Three case scenarios of asthma were given, and the doctors were asked to write a prescription for each case. Doctors were asked about their views on inhaler therapy and dietary restrictions in asthma.
Of 120 doctors, 100 (83%) responded. Thirty different regimens of short acting beta2-agonist and 16 regimens of steroid therapy were prescribed by the practitioners. Only 35% of the doctors prescribed corticosteroids for persistent asthma symptoms. The great majority of doctors were not aware of treatment options for persistent symptoms despite the use of preventive therapy (8% prescribed long-acting beta2-agonists, 6% high-dose inhaled corticosteroids and 13% theophyllines). Misconceptions about inhaler therapy and diet were found in 20 and 50 doctors, respectively.
General practitioners in Pakistan did not follow asthma management guidelines. There was serious lack of knowledge about asthma medications coupled with misconceptions about inhaler therapy and dietary factors.
The Venn diagram of obstructive lung disease (OLD) has been recently quantified. We aimed to quantify the proportion of the general population with OLD, and the intersections of physician-diagnosed asthma, chronic bronchitis (CB), and emphysema in two Italian general population samples, in relationship to airflow obstruction (AO) determined through spirometry.
We analyzed data from two prospective studies (4,353 patients) carried out in the rural area of Po River delta from 1988 to 1991 and in the urban area of Pisa from 1991 to 1993.
Prevalence rates of asthma, CB, and emphysema were 5.3%, 1.5%, and 1.2% in the Po delta, and 6.5%, 2.5%, and 3.6% in Pisa. A double Venn diagram, which was used to quantify the distribution of CB, emphysema, and asthma in relation to the presence/absence of AO, identified 15 categories. Isolated AO was the most frequent category (Po delta, 11.0%; Pisa, 6.7%), followed by asthma only without AO (Po delta, 3.3%; Pisa, 4.3%). The combination of the three OLD conditions was the only category that always showed higher prevalence rates for those with AO (Po delta, 0.20%; Pisa, 0.16%) than for those without AO (Po delta, 0.04%; Pisa, 0.05%). Of those with either OLD or AO, there were 61.4% in Po delta and 38.2% in Pisa with isolated AO, 24.8% and 41.9%, respectively, with an OLD without AO, and 13.8% and 19.9%, respectively, with simultaneous OLD and AO. For both genders, the frequency of isolated asthma decreased with age, while that of isolated AO, CB-emphysema, and the combination of asthma and CB-emphysema increased.
About 18% of the Italian general population samples either reported the presence of OLD or showed spirometric signs of AO. We confirmed that the Venn diagram of OLD can be quantified in the general population by extending the mutually exclusive disease categories (including a concomitant diagnosis of asthma, CB, or emphysema) to 15.
Several studies have provided evidence of a strong association between asthma and allergic or nonallergic rhinitis, leading to the hypothesis that allergic rhinitis (AR) and asthma represent a continuum of the same disease.
The aims of our study were: (i) to measure the comorbidity of AR and asthma and asthma-like symptoms and (ii) to assess whether asthma, AR, and their coexistence share a common pattern of individual risk factors.
The subjects are participants from the Italian multicentre, cross-sectional survey on respiratory symptoms in the young adult general population (Italian Study of Asthma in Young Adults, ISAYA). The relationship between individual risk factors and asthma, AR and their coexistence, was studied by means of a multinomial logistic regression.
About 60% of asthmatics reported AR. On the other hand, subjects with AR presented an eightfold risk of having asthma compared to subjects without AR. Age was negatively associated with asthma [OR = 0.89, 95% confidence interval (CI): 0.82-0.96], AR (OR = 0.92, 95% CI: 0.86-0.98), and asthma associated with AR (OR = 0.83, 95% CI: 0.79-0.88). The risk of AR without asthma was significantly higher in the upper social classes (OR = 1.23, 95% CI: 1.08-1.39). Active current smoking exposure was positively associated with asthma alone (OR = 1.24, 95% CI: 1.09-1.41) and negatively associated with AR with (OR = 0.69, 95% CI: 0.54-0.88) or without (OR = 0.76, 95% CI: 0.69-0.84) asthma.
Asthma and AR coexist in a substantial percentage of patients; bronchial asthma and AR, when associated, seem to share the same risk factors as AR alone while asthma without AR seems to be a different condition, at least with respect to some relevant risk factors.
Asthma guidelines, established by the National Asthma Education and Prevention Panel (NAEPP), seek to guide physicians in the appropriate assessment and treatment of asthma. Poor physician adherence to these guidelines has been documented because of a variety of reported barriers. We sought to test the efficacy of the Community Asthma Program (CAP), which was designed to help primary care physicians (PCP) assess asthma severity and to prescribe medications according to NAEPP guidelines. A prospective, observational study was conducted in 723 patients with asthma (aged < 1-85 years) in two primary care clinics. PCPs had access to patient responses to asthma symptom questions at each visit. The correlations between patient self-reported and PCP-classified asthma severity, treatment prescribed, and missed days from work or school were determined. The effect of the intervention on guideline adherence was assessed by asthma severity level and time. An overall moderate measure of agreement was found between patient self-reported and PCP-classified asthma severity (kappa = 0.48; p < 0.001) although this agreement decreased with increasing severity of asthma. Patient self-reported (r = 0.14; p < 0.001) and PCP-classified (r = 0.17; p < 0.001) asthma severity was weakly correlated with missed days from work or school. Those with severe persistent asthma were 89% less likely to be appropriately treated than the mild intermittent group (OR = 0.11; 95% CI-0.1-0.2). This relationship was not influenced by the different clinics or providers nor by the age of the patient. Over time, the CAP-trained PCPs were more likely to appropriately prescribe asthma medications for those with moderate to severe asthma (Mantel-Haenszel chi2 = 5.11; p = 0.02). Despite appropriate assessment of asthma severity, physicians are undertreating patients with severe asthma, the group with the highest health care use. Use of the CAP over time aided PCPs in appropriately medicating patients with moderate to severe asthma in accordance with guidelines.
A large number of prescribing quality indicators based on register data have been proposed and many are used routinely in quality management. Often the content and face validity of indicators have been assessed by consensus methods, but studies analysing other validity aspects are scarce. Prescription data are frequently used for indicators, but they do not provide any direct information about disease and patient factors important for judging the quality of prescribing. If register-based proxies for diagnoses, disease severity or risk factors are employed, validation is essential. The concurrent validity of indicators should be assessed by comparing to a "gold standard" quality assessment at the patient level using all available clinical information. The validity of frequently used quality indicators of asthma treatment has been questioned and should be further investigated. NSAID prescribing indicators are currently under evaluation. In the future, detailed clinical information from practice databases and computerised hospital records will be an important data source for indicators and for validation studies. Furthermore, the statistical and epidemiological properties of prescribing quality indicators need more attention.
Allergic rhinitis (AR) represents a major challenge in primary care. The Allergic Rhinitis and its Impact on Asthma (ARIA) group proposed a new classification for AR and developed evidence-based guidelines for the management of this disease. We conducted this study to further characterize the classes of AR described by ARIA, and to evaluate whether the management of AR in general practice is in accordance with the ARIA guidelines.
During the pollen season of 2003, 95 Belgian general practitioners (GPs) enrolled 804 patients who presented with symptoms of AR. For each patient, a questionnaire comprising the clinical presentation and management was completed.
In 64% of the patients, AR was classified as intermittent and in 36% as persistent. Persistent rhinitis caused more discomfort than intermittent rhinitis. Only 50% of the patients had ever undergone allergy testing. Among them, 51% were allergic to both seasonal and perennial allergens. Eighty-two per cent of the persistent rhinitics were allergic to at least one seasonal allergen and 72% of the intermittent rhinitics to at least one perennial allergen. When compared strictly with the ARIA recommendations, 49% of the patients with mild and/or intermittent AR were overtreated, whereas about 30% of those with moderate/severe persistent rhinitis were undertreated.
This study confirms that the previous classification of AR into 'seasonal' and 'perennial' is not satisfactory and that intermittent and persistent AR are not equivalent to seasonal and perennial AR respectively. Furthermore, persistent rhinitis has been shown to be a distinct disease entity. Further efforts are required to disseminate and implement evidence-based diagnostic and treatment guidelines for AR in primary care practice.
A major reason of the poor control of asthma is that patients fail to adhere to their treatment. The aim of the study was to identify factors affecting changes in asthma treatment adherence in an international cohort.
A follow-up study was carried out by means of a structured clinical interview in 971 subjects with asthma from 12 countries who participated in both the European Community Respiratory Health Survey: ECRHS-I (1990-94) and ECRHS-II (1998-2002). Subjects were considered adherent if they reported they normally took all the prescribed drugs. A logistic model was used to study the adjusted effect of the determinants.
The net change in adherence to anti-asthmatic treatment per 10 years of follow-up was -2% (95% CI: -9.5, 5.5), 7.5% (-2.6, 17.6), 15.0% (6.6, 23.5) and 19.8% (4.1, 35.5), respectively, in Nordic, Mediterranean, Continental and extra-European areas. Among the 428 non-adherent subjects in ECRHS-I, having regular consultations with health care professionals was the strongest predictor of increased adherence (OR 3.32; 95% CI: 1.08-10.17). Among the 543 adherent subjects in ECRHS-I, using inhaled corticosteroids significantly predicted a persistence of adherence (OR 2.04; 95% CI: 1.11-3.75). No effect of gender, age, duration of the disease, smoking habit and educational level was observed.
Our findings highlight the key role of doctors and nurses in educating and regularly reviewing the patients and support the efforts for an improvement of clinical communication.
To examine the level of physician adherence to the Expert Panel Report 2 (EPR-2) pharmacotherapy guidelines of the asthma population, specifically in the elderly ambulatory patient population of the United States.
Retrospective cross-sectional study using a national survey.
National Ambulatory Medical Care Survey data of U.S. elderly patients from 1998 through 2004.
The weighted population sample size was 82,020,318 patients. There were 1,540 observations in this study (preweighted sample size) and 96 strata, with 446 population sampling units (PSUs). There were 11,868,340 patients that were elderly, and they accounted for 14.5% of the overall population sampled.
Specific patient demographic variables, physician demographic variables, and information about asthma medications prescribed were extracted from the data set and analyzed. Descriptive statistics for the patient demographic, physician demographic, and asthma pharmacotherapy variables were generated. A series of logistic regression models were created, with the choice of asthma pharmacotherapy agent used as the dependent variable and patient and physician demographic variables as the independent variables.
A major finding was that physicians were not adherent to the National Asthma Education and Prevention Program EPR-2 asthma pharmacotherapy guidelines. Another finding was that, although elderly patients (aged >or=65) were exposed to more-stable patterns of care, they were less likely to be prescribed controller medications, long-acting bronchodilators (LABAs), combinations of inhaled corticosteroids and LABAs, and short-acting beta agonists than patients aged 35 to 64.
A more-concerted effort needs to be undertaken to improve physician adherence to the EPR-2 guidelines, especially in prescribing asthma pharmacotherapy to elderly patients.
Community Asthma Program improves appropriate prescribing in moderate to severe asthma Global Strategy for Asthma Management and prevention
- Moonie
- Sa
- Rc Strunk
- Curtis S V Crocker
- K Schechtman
- Castro
Moonie SA, Strunk RC, Crocker S, Curtis V, Schechtman K, Castro M. Community Asthma Program improves appropriate prescribing in moderate to severe asthma. J Asthma 2005;42: 281e9. 19. GINA report, Global Strategy for Asthma Management and prevention; 2006 Revision.
Are Hong Kong doctors following the Global Initiative for Asthma guidelines: a questionnaire
- Ko
- Chan Am Fw
- Chan Hs Ay Kong
- Rc Leung
- Ty Mok
Ko FW, Chan AM, Chan HS, Kong AY, Leung RC, Mok TY, et al. Are Hong Kong doctors following the Global Initiative for Asthma guidelines: a questionnaire " Survey on Asthma Management " ? Hong Kong Med J 2010;16:86e93.
American College of Chest Physicians Health and Science Policy Committee. Continuing medical education effect on physician knowledge applica-tion and psychomotor skills: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines
- O Km Neil
- Addrizzo-Harris
- Dj
O'Neil KM, Addrizzo-Harris DJ; American College of Chest Physicians Health and Science Policy Committee. Continuing medical education effect on physician knowledge applica-tion and psychomotor skills: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines. Chest 2009;135: 37Se41S.
Available from: http/www.ginasthma.org
- Global Strategy
- Asthma Management
- Prevention Gina
Global Strategy for Asthma Management and Prevention. GINA
report. Available from: http/www.ginasthma.org [updated
2009].