Moeilijk behandelbaar astma En de rol van het alfabet... Disclosure belangen P.J.Honkoop (potentiële) belangenverstrengeling Voor bijeenkomst mogelijk relevante relaties met bedrijven Sponsoring of onderzoeksgeld Honorarium of andere (financiële) vergoeding Aandeelhouder Andere relatie, namelijk Geen / Zie hieronder Bedrijfsnamen 1
Co-auteurs + RD last 3 years: research grants, unrestricted educational grants and/or fees for lectures and advisory board meetings from Almirall, AstraZeneca, Boehringer-Ingelheim, Chiesi, GSK, Mundipharma, Novartis, Takeda and Teva. + JCCMiV last 3 years: research grants, unrestricted educational grants and/or fees for lectures and advisory board meetings from AstraZeneca, Boehringer-Ingelheim, Chiesi, GSK, Lilly, Novartis and Teva. UK review 2014 +195 Astma doden: 49% alleen bekend in eerste lijn 49% inhalatie instructie 69% op spreekuur afgelopen jaar 47% ooit opgenomen 67% minimaal 1 preventable factor Royal College of Physicians. Why asthma still kills 2014 2
Definitie +Moeilijk behandelbaar astma is astma dat de behandelaar of de patient als moeilijk ervaart 3
Activiteiten Wie 1. Identificatie: 32 kaderhuisartsen 3. 2. 1. - Literatuur Prioriteren Selecteren Identificeren 10 praktijkondersteuners - Simples Exacerbaties - Experts Rank 1 2 3 4 5 6 7 Absoluut niet Neutraal Absoluut Een Welke astma actie onderwerpen plan relevant voor elke patiënt moeten met moeilijkzeker behandelbaar aan bod noodzakelijk 1 20 kaderhuisartsen astma 2. Selectie: komen in een nascholing over 6 moeilijk praktijkondersteuners - Score 1-7 8 longartsen De Identificatie rol van van eenmensen met een verhoogd risico op exacerbaties 2 -behandelbaar 80% 5 of hoger astma? 4 longverpleegkundigen 6 patiënten X of CT-thorax Definitie van een (ernstige) astma exacerbatie 3 3. Herkenning Prioritering: van oorzaken van exacerbaties Idem 4 - Onderverdeling in onderwerpen - Belangrijkste per onderwerp 4
Resultaten Identificatie 67 Selectie 48 Prioritering 28 Het Alfabet A. Is het astma? Is het alleen astma? B. Blootstelling C. Controle D. Device E. Exacerbaties F. Farmacotherapie G. Gedrag H. Hulp I. Individueel Zorgplan 5
In de praktijk +Alfabet voor systematische analyse moeilijke patienten +Differentiatie 1e en 2e lijn patiënten +Invulling individueel zorgplan Vervolg +CAHAG onderwijsteam +Nascholing: Moeilijk behandelbaar astma 6
SIMPLES +Smoking status +Inhaler Technique +Monitoring +Pharmacotherapy +Lifestyle +Education +Support 7
+Asthma (dutch: astma). Is it asthma, is it only asthma Explanation what is difficult to manage asthma Identification of patients with difficult to manage asthma What is the difference between difficult to manage asthma and severe asthma Role of different fenotypes of asthma Which other tests should/could be performed other than symptoms and spirometry, to diagnose asthma The role of comorbidity in asthma How to assess different fenotypes of asthma in a patient Differential diagnosis of asthma and which potential concurrent diagnoses require further investigation Further insight into the potential consequences of a diagnosis of severe asthma (such as the use of biologicals, revalidation-therapy, high-altitude treatment..) Bronchial challenge (Blootstelling). Allergens and irritants causing symptoms +Effect of smoking on asthma +Insight into allergens +Insight into aspecific irritants +Role of passive smoking +Insight into occupational irritants +Insight into hobby-related irritants +Knowledge about the relation between symptoms and work 8
+Control (Controle). How to assess and monitor asthma control +Determining current control +Content of monitoring in the individual patient +Role of the ACQ +Frequency of monitoring for the individual patient +Clear guidelines for referrals between primary and secondary care +Identification of patients suitable for pulmonary rehabilitation +Device (Device). Which device and how to use it? +Role of inhalation instruction +Inventarisation of adherence +Role of device type 9
+Exacerbation (Exacerbatie). How to prevent, detect and treat exacerbations +An asthma action plan for every difficult to manage asthma patient +Identification of patients with an increased risk +Definition of a (severe) asthma exacerbation +Recognition of causing agents of exacerbations +Farmacotherapy (Farmacotherapie). Which types of medication for which individual patient Denominate central role inhaled corticosteroids Patient perceptions on benefits and necessity medications Farmacotherapy for specific subgroups: does comorbidity determine medication choices Name common side-effects different types of medication 10
+Help (Hulp). Who can aid a patient in disease management Identification of obstacles for adherence (social, financial, societal) Education on asthma Insight into the patients personal environment +Individualised care plan (Individueel Zorg Plan). How to create and use a Self management plan for each individual patient. +Self-management for all people with (difficult to manage) asthma +Necessity of an individual care plan for all patients with (difficult to manage) asthma +Recognition and acceptance of personal limitations +Determining personal goals of treatment. +Identification of patients suited to different types of self- management: paper, online, real-life +How to make patients aware of asthma worsening events/behaviour +Estimation of desire and potential for behavioural changes 11