Bart Thoonen

Asthma education tailored to individual patient needs can optimise partnerships in asthma self-management.

This paper studies the effects of patient education, tailored to individual needs of patients as part of an asthma self-management program. A tailored education program was designed which took into account individual information needs of patients by using a feedback instrument. Totally 98 steroid dependent asthmatics entered the tailored education program, 95 patients received usual care. Outcome measures were information exchanged and patient satisfaction. Study duration was 6 months. Patients in the tailored education group showed a significant reduction in information need (P=0.005). Patient satisfaction increased from 87.9 to 93.7 in this group while this did not change in the usual care group (P=0.000). Use of this tailored education program improved the GP-patient interaction within the context of a clinically effective asthma self-management program. Findings from this study may be applicable to other chronic conditions as well.

Self management in asthma care: Professionals must rethink their role if they are to guide patients successfully

Papers p 1507 Equipping people with asthma with the tools they need to manage their condition is as important as writing the correct prescription,” according to the United Kingdoms National Asthma campaign. Guided self management has an established place in asthma guidelines and recommendations.1-2 Yet the reality of everyday asthma care is quite different from that which the guidelines suggest, as shown by Jones et al in this issue (p 1507).3 Even among general practitioners in an academic setting, asthma remains underdiagnosed and poorly treated,4 despite increased awareness of the condition. Professionals perceive asthma as a lifelong problem, but patients discontinue treatment after a few years or do not consult health professionals at all.5 General practitioners and nurses have an important role in implementing self care programmes. However, Jones et al report that patient self management …

Should the diagnosis of COPD be based on a single spirometry test

Clinical guidelines indicate that a chronic obstructive pulmonary disease (COPD) diagnosis is made from a single spirometry test. However, long-term stability of diagnosis based on forced expiratory volume in 1 s over forced vital capacity (FEV1/FVC) ratio has not been reported. In primary care subjects at risk for COPD, we investigated shifts in diagnostic category (obstructed/non-obstructed). The data were from symptomatic 40+ years (ex-)smokers referred for diagnostic spirometry, with three spirometry tests, each 12±2 months apart. The obstruction was based on post-bronchodilator FEV1/FVC < lower limit of normal (LLN) and <0.70 (fixed ratio). A total of 2,352 subjects (54% male, post-bronchodilator FEV1 76.5% predicted) were studied. By LLN definition, 32.2% were obstructed at baseline, but 32.2% of them were no longer obstructed at years 1 and/or 2. By fixed ratio, these figures were 46.6 and 23.8%, respectively. Overall, 14.3% of subjects changed diagnostic category by 1 year and 15.4% by 2 years when applying the LLN cut-off, and 15.1 and 14.6% by fixed ratio. Change from obstructed to non-obstructed was more likely for patients with higher body mass index (BMI) and baseline short-acting bronchodilator (SABA) users, and less likely for older subjects, those with lower FEV1% predicted, baseline inhaled steroid users, and current smokers or SABA users at year 1. Change from non-obstructed to obstructed was more likely for males, older subjects, current smokers and patients with lower baseline FEV1% predicted, and less likely for those with higher baseline BMI. Up to one-third of symptomatic (ex-)smokers with baseline obstruction on diagnostic spirometry had shifted to non-obstructed when routinely re-tested after 1 or 2 years. Given the implications for patients and health systems of a diagnosis of COPD, it should not be based on a single spirometry test.

Implementation strategies of internet-based asthma self-management support in usual care. Study protocol for the IMPASSE cluster randomized trial.

BackgroundInternet-based self-management (IBSM) support cost-effectively improves asthma control, asthma related quality of life, number of symptom-free days, and lung function in patients with mild to moderate persistent asthma. The current challenge is to implement IBSM in clinical practice.Methods/designThis study is a three-arm cluster randomized trial with a cluster pre-randomisation design and 12 months follow-up per practice comparing the following three IBSM implementation strategies: minimum strategy (MS): dissemination of the IBSM program; intermediate strategy (IS): MS + start-up support for professionals (i.e., support in selection of the appropriate population and training of professionals); and extended strategy (ES): IS + additional training and ongoing support for professionals. Because the implementation strategies (interventions) are primarily targeted at general practices, randomisation will occur at practice level.In this study, we aim to evaluate 14 primary care practices per strategy in the Leiden-The Hague region, involving 140 patients per arm. Patients aged 18 to 50 years, with a physician diagnosis of asthma, prescription of inhaled corticosteroids, and/or montelukast for ≥3 months in the previous year are eligible to participate. Primary outcome measures are the proportion of referred patients that participate in IBSM, and the proportion of patients that have clinically relevant improvement in the asthma-related quality of life. The secondary effect measures are clinical outcomes (asthma control, lung function, usage of airway treatment, and presence of exacerbations); self-management related outcomes (health education impact, medication adherence, and illness perceptions); and patient utilities. Process measures are the proportion of practices that participate in IBSM and adherence of professionals to implementation strategies. Cost-effective measurements are medical costs and healthcare consumption. Follow-up is six months per patient.DiscussionThis study provides insight in the amount of support that is required by general practices for cost-effective implementation of IBSM. Additionally, design and results can be beneficial for implementation of other self-management initiatives in clinical practice.Trial registrationthe Netherlands National Trial Register NTR2970

PELICAN: A quality of life instrument for childhood asthma: Study Protocol of two Randomized Controlled Trials in Primary and Specialized Care in the Netherlands

BackgroundAsthma is one of the major chronic health problems in children in the Netherlands. The Pelican is a paediatric asthma-related quality of life instrument for children with asthma from 6–11 years old, which is suitable for clinical practice in primary and specialized care. Based on this instrument, we developed a self-management treatment to improve asthma-related quality of life. The Pelican intervention will be investigated in different health care settings. Results of intervention studies are often extrapolated to other health care settings than originally investigated. Because of differences in organization, disease severity, patient characteristics and care provision between health care settings, extrapolating research results could lead to unnecessary health costs without the desired health care achievements. Therefore, interventions have to be investigated in different health care settings when possible. This study is an example of an intervention study in different health care settings. In this article, we will present the study protocol of the Pelican study in primary and specialized care.Method/designThis study consists of two randomized controlled trials to assess the effectiveness of the Pelican intervention in primary and specialized care. The trial in primary care is a multilevel design with 170 children with asthma in 16 general practices. All children in one general practices are allocated to the same treatment group. The trial in specialized care is a multicentre trial with 100 children with asthma. Children in one outpatient clinic are randomly allocated to the intervention or usual care group. In both trials, children will visit the care provider four times during a follow-up of nine months. This study is registered and ethically approved.DiscussionThis article describes the study protocol of the Pelican study in different health care settings. If the Pelican intervention proves to be effective and efficient, implementation in primary and specialized care for paediatric asthma in the Netherlands will be recommended.Trial registrationThis study is registered by clinicaltrial.gov (NCT01109745)

Influence of house dust mite impermeable covers on health-related quality of life of adult patients with asthma: results of a randomized clinical trial.

The aim of this study was to evaluate the effect of house dust mite impermeable covers on asthma-specific health-related quality of life in adult asthmatic patients that were trained in guided self-management. In a 2-year randomized placebo-controlled clinical trial, information on the quality of life was collected. The improvement of Mini Asthma Quality of Life Questionnaire (AQLQ) score in the allergens-avoidance group (0.26) was comparable to the improvement in the placebo group (0.30) and not significant. HDM-impermeable covers for pillows, duvets, and mattresses did not result in improved health-related quality of life.

Role of family physicians in implementing asthma self-management programs.

The reality of everyday asthma care differs substantially from guidelines. The fact that better possibilities for asthma care do not result in better outcomes remains an enigma and harms professional pride. Patient self-management has been presented as a tool to improve outcome of care. Based on published work thus far, it can be concluded that self-management of asthma can be beneficial from both the family physicians’ and the patients’ perspective and, under certain conditions, proves to be an efficient method of incorporating both interests. Health professionals play an important role in implementing self-care, but several barriers should be solved first: attitudes of health professionals and patients need to shift towards shared responsibilities and be patient-centered and organization of care should change accordingly. As reviewed in this article, the typical features of self-management of asthma may provide the means to overcome these barriers.

Kan de diagnose COPD op één spirometrietest berusten

SamenvattingSchermer TR, Robberts B, Grootens J, Lucas A, Thoonen BP, Smeele IJ. Kan de diagnose COPD op één spirometrietest berusten? Huisarts Wet 2017;60(10):497-9. Huisartsen stellen de diagnose COPD vaak op basis van één spirometrietest. Een te lage post-bronchodilatoire FEV1/FVC wijst dan op een luchtwegobstructie die kan passen bij COPD. In een onderzoek onder 2352 personen met verdenking op COPD, die door hun huisarts waren verwezen naar huisartsenlaboratoria, bleken aanvankelijk 758 personen (32%) luchtwegobstructie te vertonen. Na een jaar was dit bij 22% (168/758) en na twee jaar bij 32% (244/758) echter niet meer het geval. Van de 1594 personen zonder obstructie bij de eerste spirometrietest was na een jaar bij 90% wederom geen sprake van obstructie; na twee jaar bij 85%. Verschillende persoonskenmerken voorspelden de kans op verschuiving van obstructief naar niet-obstructief. De FEV1/FVC en het daarop gebaseerde oordeel wel/niet obstructief varieert dusdanig in de tijd dat eenmalige spirometrie leidt tot over- en onderdiagnostiek van COPD.

Verlaagde geforceerde vitale capaciteit

SamenvattingMijnheer Veldberg is een 57-jarige man die nieuw op het astma-COPD spreekuur komt voor een vervolgconsult naar aanleiding van chronische hoestklachten en dagelijks last van kortademigheid. Hij vertelt na 100 meter lopen te moeten stoppen om op adem te komen (MRC-score 3). Hij rookt fors (42 pakjaren). U verricht een spirometrie als onderdeel van het consult. De blaastechniek van mijnheer Veldberg is goed en hij is in staat om 3 reproduceerbare metingen te blazen. Hieronder ziet u de beste metingen voor en na bronchodilatatie (BD). De rode curve is de pre-BD-meting, de blauwe curve de post-BD-meting.

De kwaliteit van spirometrie

SamenvattingMijnheer De Boer is een 61-jarige man. Hij heeft al jaren last van slijm en hoesten. De laatste tijd neemt dat toe. Er zijn geen klachten van kortademigheid. Mijnheer De Boer heeft de afgelopen 10 jaar pijp gerookt en is begin dit jaar gestopt. In het verleden had hij geen astma of atopie, maar in de familie komen eczeem en astma/bronchitis voor. De huisarts besluit om spirometrie te doen. Hieronder zie je de curves van de pre- en post-tests met de bijbehorende getallen.