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Grazie per aver scelto di utilizzare a scopo didattico questo materiale delle Guidelines 2011 libra. Le ricordiamo che questo materiale è di proprietà dell’autore e fornito come supporto didattico per uso personale. Modena LIBRA, March 1st,2011. Unmet Needs in ASTHMA and COPD.

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Prof. Giorgio Walter Canonica Allergy and Respiratory Diseases Department University of Genoa

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Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Grazie per aver scelto di utilizzare a scopo didattico questo materiale delle Guidelines 2011 libra.Le ricordiamo che questo materiale è di proprietà dell’autore e fornito come supporto didattico per uso personale.


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Modena LIBRA, March 1st,2011

Unmet Needs in

ASTHMA and COPD

Prof. Giorgio Walter Canonica

Allergy and Respiratory Diseases Department

University of Genoa

Past President

1°vice President


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

COPD


Calverley b j p 2008

Calverley, B.J.P. 2008


Calverley b j p 20081

Calverley, B.J.P. 2008


Decramer et al resp med 2011

Decramer et al. Resp.Med.2011


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Decramer et al. Resp.Med.2011


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Decramer et al. Resp.Med.2011


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

CONCLUSIONS

Decramer et al. Resp.Med.2011


Morales asenco et al bmc 2010

Morales Asenco et al. BMC 2010


Pros patient reported outcomes

PROsPatient Reported Outcomes


Real life observational studies

Real-life observational studies

Patientreported

outcomes

Disease

phenotype

Therapy

Diseasecontrol

measures

Aetiology

Severity

Comorbidities

Drugs

Schedule

Symptoms Score

Composite Score

Function

Biology

Clinical parameters

Resource utilisation

Preference

Awareness

Satisfaction

Behaviour

Coping

Adherence

Stress

Anxiety/depression

Quality of life

Alexithymia

Mood


Braido et al cmro 2011

Braido et al. CMRO 2011


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Braido et al. CMRO 2011


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Braido et al. CMRO 2011


Asthma

ASTHMA


Guidelines

GUIDELINES


Asthma guidelines

Asthma guidelines


Asthma control in real life

Asthma Control inReal Life


Worldwide epidemiological evaluation of asthma control level

Worldwide epidemiological evaluation of asthma control level

2509 patients with asthma2

7 European countries

2803 patients with asthma1

AIRLA

Asthma Insights and Reality in Latin America

8 Asian-Pacific countries

3206 patients with asthma3

11 Latin American countries

2184 patients with asthma

1. Rabe et al. Eur Respir J 2000; 16: 802-8072. www.asthmainamerica.com 3. Lai et al. Eur Respir J 2003; 111: 263-268


Achieving control in asthmatic patients still a critical issue

Achieving control in asthmatic patients: still a critical issue?

Braido et al. Allergy 2009; 64: 937-943

Total control

Well controlled

Uncontrolled

122 patients51.3% LABA + ICS16 PTZ high-dose L + I

patients treated with

high-dose ICS + LABA

the total sample

Levels of asthma control in the total sample (right), and in the subgroup of patients treated with high-dose ICS + LABA (left)


Patients opinions on their asthma

Patients’ opinions on their asthma

Asthma

96 patients

Do you think your disease is under control?

Do you think you relied on qualified professionals?

How do you cope with your disease?

Have drugs improved your disease?

Are you following doctors’ prescriptions?

Do you think your disease will improve?

Do you feel helped by your family?

Do you feel helped by all the medical staff?

Not at all

3.1%

1.0%

19.8%

8.3%

A little

12.5%

7.3%

16.7%

14.6%

5.2%

33.3%

7.3%

10.4%

Fairly

58.3%

53.1%

51.0%

53.1%

50.0%

26.0%

36.5%

66.7%

A lot

22.9%

32.3%

24.0%

26.0%

39.6%

9.4%

33.3%

21.9%

Not indicated

6.3%

7.3%

5.2%

6.3%

4.2%

11.5%

14.6%

1.0%

Baiardini et al. J Investig Allergol Clin Immunol 2006; 16: 218-223


Real life asthma management

Real-life asthma management

Braido et al. J Investig Allergol Clin Immunol 2010; 20: 9-12


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Why do doctors and patients not follow guidelines?

Baiardini et al.

Curr Opin Allergy Clin Immunol 2009; 9: 228-233


Why do doctors not follow guidelines

Why do doctors not follow guidelines?

  • LACK of:

  • Consciousness

  • Familiarity

  • Agreement

  • Auto- effectiveness

  • Success expectation

  • Motivation and consolidation

  • External barriers

Baiardini et al. Curr Opin Allergy Clin Immunol 2009; 9: 228-233


Why do patients not follow guidelines

Why do patients not follow guidelines?

Baiardini et al. Curr Opin Allergy Clin Immunol 2009; 9: 228-233


Adherence to treatment is a weak point in asthma management

Adherence to treatmentis a weak pointin asthma management


World health organisation 2003

World Health Organisation2003

World Health Organisation


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Cutler and Everett. NEJM 2010; 362: 1553-1555


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Cutler and Everett. NEJM 2010; 362: 1553-1555


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Cutler and Everett. NEJM 2010; 362: 1553-1555


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

COPD


Overall persistence with single and fixed ics treatment in new users with asthma

Breekveldt-Postma et al. Pharmacoepidemiol Drug Saf 2008; 17: 411-422

Overall persistence with single and fixed ICS treatment in new users with asthma

Fixed

Single

Adults

Children and adolescents

1.0

1.0

0.8

0.8

0.6

0.6

Proportion of persistent ICS users by formulation in adults

Proportion of persistent ICS users by formulation in children and adolescents

0.4

0.4

0.2

0.2

0.0

0.0

0

50

100

150

200

250

300

350

400

0

50

100

150

200

250

300

350

400

Time since start of therapy (days)

Time since start of therapy (days)


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Unmet needs in asthma: Global Asthma Physician and Patient (GAPP Survey): global adult findings

Canonica et al. Allergy 2007; 62: 668-674


Patients and physicians disagree on content of education provided and received

Patients and physicians disagree on content of education provided and received

Correct inhaler technique

Develop individual management plan

Patients perceive that only 25% of office visit time is devoted to asthma education

Monitor peak expiratory flow

Keep daily symptom/medication diaries

Contact patient support organisation

Respondents (%)

Does your doctor or other healthcare professional in his or her office discuss any of the following with you? Base: all respondents (patients)

Do you regularly discuss the following with your asthma patients? Base: all respondents (physicians)

Canonica et al. Allergy 2007; 62: 668-674


Treatment compliance increases with increased patient education

Treatment compliance increases with increased patient education

Patient treatment compliance

Amount of time spent on patient education

<51%

15%

51-80%

27%

81-99%

29%

100%

30%

Increase in compliance (%)

Canonica et al. Allergy 2007; 62: 668-674


Time with doctor in primary care

Time with doctor in primary care

Malaysia5-10 mins

Pakistan<3 mins

UK8 mins

Australia15 mins

South Africa 8-11 mins

Italy 8 mins

E Bateman


This should be avoided

This should be avoided!!!


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Can asthma control be improved by understanding the patient’s perspective?

Patient

Horne et al. BMC Pulm Med 2007; 7: 8


Asthma physician s and patient s viewpoint two different perspectives

Asthma: physician’s and patient’s viewpoint – two different perspectives

Asthma

Inflammation

Comorbidity

IgE

Atopy

Histamine

Bronchoconstriction

FEV1

Asthma

Sleep

Eating

Physical functioning

Social life

Sport

Work Performance

Mental functioning

School Performance

Physician

Patient


A general process in guidelines evolution

A general process in guidelines evolution

Evidence-based medicine


Factors that influence the strength of a recommendation

Factors that influence the strength of a recommendation

  • Balance between desirable and undesirable effects

  • Quality of evidence

  • Patients’ values and preferences

  • Costs


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

PROs to support medical product labelling claims:FDA perspective

PROs provide a unique perspective on medical therapy, because some effects of a health condition and its therapy are known only to patients

Patrick et al. Value Health 2007; 10 (Suppl 2): S125-S137

FDA, Food and Drug Administration


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Braido et al. Allergy 2010: DOI: 10.1111/j.1398-9995.2010.02383.x.


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Baiardini et al. J.ASTHMA 2011


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Baiardini et al. J.ASTHMA 2011


Physician s and patient s viewpoint

Physician’s and patient’s viewpoint

Diagnosis

Drugs

Follow-up

Guidelines

Severity

Comorbidity

Costs

Clinical parameters

Functional parameters

Limits

Emotions

Knowledge

Satisfaction

Fear

Sleep

School

Relationships

Education

Consideration

Disease management

Physician

Patient


Characterisation of chronic diseases

Characterisation of chronic diseases

  • Persistance, more years of disability and handicap, shorter life expectancy and can totally or partly be abrogated by a continuous action by healthcare professionals

World Health Organisation

Chronic disease management

Physical functioning

Life expectancy


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Take home messages

Disease Management is crucial

PROs should be priority outcomes

of treatments

Adherence to treatment

is our ultimate goal


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Knowledge and health care resources allocation in asthma management: impact of one-year guidelines based CME/CPD course Braido F*, Comaschi M°, Valle I§, Delgado L+, Coccini A§, Guerrera P°°, Stagi E**, Canonica GW* on behalf of ARGA Study Groupand EAACI/CME Committee f.

Braido F* et al. submitted


Braido f et al submitted

Braido F* et al. submitted

  • Material and methods

  • Study design

  • The educational program was made up

    of 5 residential events with 4 short distance learning courses in-between.

  • The scientific contents of the courses were based on the economical analysis of Anatomical Therapeutic Chemical Classification System (ATC) Respiratory (R) drugs prescription and healthcare resource usage data related to the previous three-months, blindly obtained from the database of Local Health Unit ASL No 3 of Genoa.


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Braido F* et al. submitted


Single drug prescriptions

Single Drug Prescriptions

Braido F* et al. submitted


Results

Results

  • Fourteen GPs (46.7%) completed the training course and 6 (20%) completed the distance-learning part.

  • Knowledge improved significantly after training (p <0.001, correct answers to key questions +13%).

  • Training resulted in pharmaceutical cost containment (trained GPs +0.5% vs controls +18.8%) and greater attention to diagnosis and monitoring (increase in spirometry +63.4% , p 0.01).

Braido F* et al. submitted


Prof giorgio walter canonica allergy and respiratory diseases department university of genoa

Final Take Home Message

GUIDELINES ARE INTERVENTIONALLY EFFECTIVEWHENEVER PROPERLY IMPLEMENTED


Thank you

Thank you

Fulvio BRAIDO

Ilaria BAIARDINI

[email protected]


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