Aileen David-Wang

Time for a new language for asthma control: results from REALISE Asia

Purpose Asthma is a global health problem, and asthma prevalence in Asia is increasing. The REcognise Asthma and LInk to Symptoms and Experience Asia study assessed patients’ perception of asthma control and attitudes toward treatment in an accessible, real-life adult Asian population. Patients and methods An online survey of 2,467 patients with asthma from eight Asian countries/regions, aged 18–50 years, showed greater than or equal to two prescriptions in previous 2 years and access to social media. Patients were asked about their asthma symptoms, exacerbations and treatment type, views and perceptions of asthma control, attitudes toward asthma management, and sources of asthma information. Results Patients had a mean age of 34.2 (±7.4) years and were diagnosed with asthma for 12.5 (±9.7) years. Half had the Global Initiative for Asthma-defined uncontrolled asthma. During the previous year, 38% of patients visited the emergency department, 33% were hospitalized, and 73% had greater than or equal to one course of oral corticosteroids. About 90% of patients felt that their asthma was under control, 82% considered their condition as not serious, and 59% were concerned about their condition. In all, 66% of patients viewed asthma control as managing attacks and 24% saw it as an absence of or minimal symptoms. About 14% of patients who correctly identified their controller inhalers had controlled asthma compared to 6% who could not. Conclusion Patients consistently overestimated their level of asthma control contrary to what their symptoms suggest. They perceived control as management of exacerbations, reflective of a crisis-oriented mind-set. Interventions can leverage on patients’ trust in health care providers and desire for self-management via a new language to generate a paradigm shift toward symptom control and preventive care.

Asthma in Asia: Physician perspectives on control, inhaler use and patient communications

Abstract Objective: We examined the physician perspectives on asthma management in Asia. Methods: An online/face-to-face, questionnaire-based survey of respiratory specialists and primary care physicians from eight Asian countries/region was carried out. The survey explored asthma control, inhaler selection, technique and use; physician-patient communications and asthma education. Inclusion criteria were >50% of practice time spent on direct patient care; and treated >30 patients with asthma per month, of which >60% were aged >12 years. Results: REALISE Asia (Phase 2) involved 375 physicians with average 15.9(±6.8) years of clinical experience. 89.1% of physicians reporting use of guidelines estimated that 53.2% of their patients have well-controlled (GINA-defined) asthma. Top consideration for inhaler choice was asthma severity (82.4%) and lowest, socio-economic status (32.5%). Then 54.7% of physicians checked their patients’ inhaler techniques during consultations but 28.2(±19.1)% of patients were using their inhalers incorrectly; 21.1–57.9% of physicians could spot improper inhaler techniques in video demonstrations. And 79.6% of physicians believed combination inhalers could increase adherence because of convenience (53.7%), efficacy (52.7%) and usability (18.9%). Initial and follow-up consultations took 16.8(±8.4) and 9.2(±5.3) minutes, respectively. Most (85.1%) physicians used verbal conversations and least (24.5%), video demonstrations of inhaler use; 56.8% agreed that patient attitudes influenced their treatment approach. Conclusion: Physicians and patients have different views of ‘well-controlled’ asthma. Although physicians informed patients about asthma and inhaler usage, they overestimated actual usage and patients’ knowledge was sub-optimal. Physician-patient interactions can be augmented with understanding of patient attitudes, visual aids and ancillary support to perform physical demonstrations to improve treatment outcomes.

Personalising care of adults with asthma from Asia: a modified e-Dephi consensus study to inform management tailored to attitude and control profiles

REALISE Asia—an online questionnaire-based study of Asian asthma patients—identified five patient clusters defined in terms of their control status and attitude towards their asthma (categorised as: ‘Well-adjusted and at least partly controlled’; ‘In denial about symptoms’; ‘Tolerating with poor control’; ‘Adrift and poorly controlled’; ‘Worried with multiple symptoms’). We developed consensus recommendations for tailoring management of these attitudinal–control clusters. An expert panel undertook a three-round electronic Delphi (e-Delphi): Round 1: panellists received descriptions of the attitudinal–control clusters and provided free text recommendations for their assessment and management. Round 2: panellists prioritised Round 1 recommendations and met (or joined a teleconference) to consolidate the recommendations. Round 3: panellists voted and prioritised the remaining recommendations. Consensus was defined as Round 3 recommendations endorsed by >50% of panellists. Highest priority recommendations were those receiving the highest score. The multidisciplinary panellists (9 clinicians, 1 pharmacist and 1 health social scientist; 7 from Asia) identified consensus recommendations for all clusters. Recommended pharmacological (e.g., step-up/down; self-management; simplified regimen) and non-pharmacological approaches (e.g., trigger management, education, social support; inhaler technique) varied substantially according to each cluster’s attitude to asthma and associated psychosocial drivers of behaviour. The attitudinal–control clusters defined by REALISE Asia resonated with the international panel. Consensus was reached on appropriate tailored management approaches for all clusters. Summarised and incorporated into a structured management pathway, these recommendations could facilitate personalised care. Generalisability of these patient clusters should be assessed in other socio-economic, cultural and literacy groups and nationalities in Asia.

Development and Validation of an Attitudinal-Profiling Tool for Patients With Asthma

Purpose To develop a profiling tool which accurately assigns a patient to the appropriate attitudinal cluster for the management of asthma. Methods Attitudinal data from an online survey of 2,467 patients with asthma from 8 Asian countries/region, aged 18-50 years, having had ≥2 prescriptions in the previous 2 years and access to social media was used in a discriminant function analysis to identify a minimal set of questions for the Profiling Tool. A split-sample procedure based on 100 sets of randomly selected estimation and validation sub-samples from the original sample was used to cross-validate the Tool and assess the robustness of its predictive accuracy. Results Our Profiling Tool contained 10 attitudinal questions for the patient and 1 GINA-based level of asthma control question for the physician. It achieved a predictive accuracy of 76.2%. The estimation and validation sub-sample accuracies of 76.7% and 75.3%, respectively, were consistent with the tools predictive accuracy at 95% confidence level; and their 1.4 percentage-points difference set upper-bound estimate for the degree of over-fitting. Conclusions The Profiling Tool is highly predictive (>75%) of the attitudinal clusters that best describe patients with asthma in the Asian population. By identifying the attitudinal profile of the patient, the physician can make the appropriate asthma management decisions in practice. The challenge is to integrate its use into the consultation workflow and apply to areas where Internet resources are not available or patients who are not comfortable with the use of such technology.

P56 Efficacy and safety of long-acting beta agonists + long acting muscarinic antagonists vs. long-acting beta agonists + inhaled corticosteroids in COPD: a meta-analysis

Background and significance Current Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend the use of long-acting beta agonists (LABA) plus inhaled corticosteroids (ICS), or long-acting muscarinic antagonists (LAMA) for the treatment of patients with moderate to severe COPD. The combination of LABA+LAMA is recently indicated for COPD patients with severe symptoms; however, its role in reducing exacerbations is less clear. Methods We performed a meta-analysis of randomised controlled trials that compared efficacy and safety of LABA+LAMA versus LABA+ICS in moderate to severe COPD patients. The primary outcome is the rate of COPD exacerbations. Other outcome measures include improvement in trough FEV1, St. George Respiratory Questionnaire for COPD (SGRQ-C) scores, transition dyspnea index (TDI) scores, rescue medication use and pneumonia risk. Analysis was performed in accordance with the Quality of Reporting of Meta-Analyses (QUORUM) guidelines. Results A total of 6 RCTs with 3370 patients were included. Over-all exacerbation rates were 21% lower in those treated with LABA+LAMA versus LABA+ICS (RR 0.79, [95% CI: 0.66–0.94]). This effect is more pronounced in patients who had >1 exacerbation per year, showing 25% lower exacerbation rates (RR 0.75 [0.60–0.95]) compared to those with no history of prior exacerbations (RR 0.85 [0.61–1.14]). Patients given Indacaterol+Glycopyrronium also experienced lower rates exacerbation versus LABA+ICS (RR 0.71 [0.57–0.59]) compared to those given Umeclidinium+Vilanterol (RR 1.16 [0.68–2.00]). There were also statistically significant improvements in FEV1 (mean difference 70 mL [95% CI: 0.07–0.07 Liters]), improvement in SGRQ-C (mean difference −0.92 points [−0.95, −0.90]), improvement in TDI scores (mean difference 0.24 [0.23–0.25]) and decrease in use of rescue medications (mean difference −0.20 puffs/day[−0.21, −0.20]). Pneumonia risk was 41% lower in patients given LABA+LAMA compared LABA+ICS (RR 0.59 [0.43 – 0.80]). Conclusions The combination of LABA+LAMA is safer and more effective in reducing exacerbations and improving clinical outcomes compared with LABA+ICS in patients with moderate to severe COPD. Abstract P56 Figure 1

P143 Blood eosinophilia as predictor for patient outcomes in COPD exacerbations: a systematic review and meta-analysis

Background and significance COPD exacerbations are associated with significant morbidity, mortality, and substantial healthcare cost. The eosinophilic phenotype of COPD has been demonstrated to respond better to corticosteroids thus providing better clinical outcomes. This review aims to elucidate further the correlation between blood eosinophilia and outcomes in hospitalised patients with COPD exacerbations. Methods We systematically searched published and unpublished literature for potential studies that fulfilled our eligibility criteria. Inclusion criteria include any cohort (prospective or retrospective), case-control or randomised trials that looked into the association of blood eosinophilia and outcomes in hospitalised COPD exacerbation patients. The primary study outcome was length of hospitalisation; other outcomes include readmission and mortality rate within 1 year, in-patient mortality, and need for mechanical ventilation. An extensive eligibility, methodological and risk of bias assessments were performed independently by two authors adhering to the MOOSE and Cochrane standards. Results Six studies, with a total of 7293 patients, were included in the review. Five are retrospective cohorts and one is a retrospective analysis of a subgroup of a randomised trial. Patients with blood eosinophilia had significantly shorter hospital stay compared to non-eosinophilic patients (mean difference 0.68 days [95% CI: 1.09, 0.27]). Eosinophilic patients had significantly less frequent readmissions (odds ratio/OR 0.69 [95% CI: 0.55, 0.87]) but there was no statistically significant difference in the 1-year mortality rate (OR 0.88 [95% CI: 0.73, 1.06]). Analysis showed a trend toward lower in-patient mortality among eosinophilic patients, although this difference is not statistically significant (OR 0.53 [95% CI: 0.27, 1.05]). Furthermore, COPD patients with eosinophilia had significantly less need for mechanical ventilation during an exacerbation (OR 0.56 [95% CI: 0.35, 0.89]). Only the primary outcome was significantly heterogenous. Conclusions COPD patients with blood eosinophilia had significantly shorter hospital stay, less frequent readmissions, and are less likely to require mchanical ventilation compared to the non-eosinophilic phenotype. Abstract P143 Figure 1

Differences in patient-perceptions and levels of asthma control across 8 Asia countires: data from the REALISE Asia survey

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Preferred sources of information on asthma: data from multinational survey of patients in Asia

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Awareness and usage of inhalers among patients with asthma: findings from REALISE Asia

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